medication error by mass general causes patients wrongful death

By all accounts, 76-year-old Geraldine O. was in good health before she entered Massachusetts General Hospital on November 18 for a routine procedure. She still worked at Revere City Hall, lived on her own, cooked and ran errands. She wasn’t ready to die.

A medication error took Geraldine’s life a week after she entered Mass General. According to a report the hospital gave her family, a nurse improperly calculated the dose of an intravenous blood thinner called Lepirudin, giving her 30 times the appropriate dose. Geraldine hemorrhaged for 12 hours while in the hospital’s care before her death.

“My mother didn’t have to die,” said Geraldine’s daughter Donna. “She could have gotten better. It was this drug they overdosed her with that took her life.”

The hospital has acknowledged the mistake and admitted Geraldine’s death was preventable. A spokesperson for the hospital says they have reviewed their patient safety system and made specific changes they hope will prevent such tragedies in the future.

Geraldine’s family plans to file a wrongful death and medical malpractice lawsuit tomorrow against five doctors, two nurses and Mass General.

“Policy changes won’t bring Geraldine…back home in time for Sunday dinner with her beloved family,” said the family’s attorney.

Lack of physician oversight and hospital negligence blamed for improper dosage of blood thinner that led to woman’s death

Geraldine broke her shoulder in September. During her rehabilitation, she developed a minor urinary tract infection, which is why she was admitted to the hospital.

As a precaution, doctors prescribed Lepirudin to prevent Geraldine from developing dangerous blood clots while she was in the hospital. Unfortunately, when a nurse miscalculated the dose, there was no doctor oversight to catch the mistake.

By the time doctors realized there was a problem, nearly a day later, Geraldine was bruising and had begun bleeding internally. The overdose of anticoagulant made it impossible for her blood to clot. It was too late to save her.

“We couldn’t believe it got to that,” says her son Donald. “She was in so much pain. That’s what angers me, to see her go out like that. From a broken shoulder to this, we tried to make sense of it all.”

Two weeks after her death, Mass General admitted that Geraldine had died of a preventable medication error.

“[T]he day nurse understood the intended dosing but made an error when entering the dose into the IV pump,” reads the report given to the family. “This excessive medication dose was preventable and a result of a failure of systems within the hospital’s control.”

A Mass General spokesperson issued a statement yesterday, saying that the hospital regrets the error and that “our hearts go out to [Geraldine’s] family.”

Dosage mistakes are the single leading cause of fatal medication errors, according to numerous studies. Doctors and hospitals have a responsibility to take all reasonable steps to prevent them from happening, such as requiring doctors to oversee and check the work of administering nurses. While improving patient safety protocols after a tragic mistake is a positive step, doing so can’t change the past, and it can never make up for the tragic toll such mistakes have on patients and their families.

Source: The Boston Globe, “MGH faces suit over drug error that killed woman,” Milton J. Valencia, March 10, 2011

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