Hospital Transplants Kidney into Wrong Patient
Doctors at a California hospital transplanted a kidney into the wrong patient last month, reports the Los Angeles Times.
According to the article, USC University Hospital in Los Angeles, CA shut down its kidney transplant program on January 29 after realizing a hospital error caused doctors to transplant a donor kidney into the wrong patient. The hospital voluntarily halted kidney transplant procedures to investigate what it called a “process error,” but did not release the nature of the error.
However, a spokesperson from OneLegacy, who directs organ transplants in the city, told the newspaper that the hospital notified them that that they had transplanted a kidney into the wrong patient and that the patient suffered no harm because the kidney was a close enough match.
“The hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed,” the hospital said.
The California Department of Public Health currently investigates the incident.
“Organs were allocated appropriately. They were packaged and labeled appropriately,” Bryan Stewart, vice president of communications for OneLegacy told KABC-TV in Los Angeles. “Then through a combination of circumstances, two Type-O kidneys being transplanted at virtually the same time in the same transplant center seems to have led to human error.”
The hospital notified the United Network of Organ Sharing (UNOS) of the error.
Pharmacy Error Gives Pregnant Woman Abortion Drug Instead of Antibiotic
A Colorado pharmacy mistakenly gave a pregnant woman the wrong drug, placing the life of her unborn child at risk, reports the Denver Post.
Mareena Silva, 19, went to the Safeway pharmacy in Fort Lupton, CO to pick up a prescription for antibiotics. The pharmacy mixed up Silva’s prescription with that of another woman with a similar name. Silva returned home and unknowingly took the dangerous medication, became ill and then rushed to the hospital.
Silva, six weeks pregnant with her first child, had been given methotrexate, a drug used to treat cancer, severe psoriasis and rheumatoid arthritis. Physicians also prescribe methotrexate as a non-surgical option to abort early pregnancy.
When given for early abortion, methotrexate causes a miscarriage of the fetus two to six weeks after taking the drug. If the pregnancy does not terminate, the child has a high risk of deformities or birth defects.
Marcel Casavant, chief of pharmacology and toxology at Nationwide Children’s Hospital in Columbus, OH told ABC News that Silva’s unborn child has a 50-50 chance of having problems, even though she only took one methotrexate pill before realizing the error.
Safeway has apologized for the error and has offered to pay Silva’s medical expenses. According to the company, pharmacy staff could have avoided this tragedy by following company procedures and performing a verbal verification of the Silva’s name and birthday when she picked up her prescription.
“We understand the anxiety this has caused and the difficulty of Ms. Silva’s situation,” Safeway Inc. spokesperson Kris Staaf said in a statement. “We are redoubling our efforts to ensure that all our pharmacists follow the strict policies and procedures we have in place to prevent medication errors.”
Doctors using mobile devices to read scans and make diagnoses… “There’s an app for that.”
The U.S. Food and Drug Administration (FDA) announced today that the agency has approved the first ever application that allows doctors to view medical scan images on mobile devices, Apple Inc.’s iPhone and iPad.
Hospital radiology departments or physician’s offices will soon be able to send images from computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine technology such as positron emission tomography (PET), to a physician’s mobile device for examination and diagnosis. The new radiology software application developed by MIM Software Inc. of Cleveland, OH called Mobile MIM, will allow physicians to view, measure distance and contrast, and make notes on medical scan images received on their iPhone or iPad.
“This important mobile technology provides physicians with the ability to immediately view images and make diagnoses without having to be back at the workstation or wait for film,” said William Maisel, M.D., M.P.H., chief scientist and deputy director for science in the FDA’s Center for Devices and Radiological Health.
The FDA approved the use of Mobile MIM only when the physician has no access to a workstation. However, the Los Angeles Times reports that FDA spokesperson Erica Jefferson acknowledged that the agency would not know if physicians use the application on their mobile devices for the convenience instead of need.
The FDA worked with radiologists to evaluate the Mobile MIM app, finding it sufficient for diagnostic image interpretation under the recommended lighting conditions.
According to the FDA, the medical images may also look different from mobile device to mobile device, even between devices of the same model, due to significant variations in the luminance levels of the devices. Because of this, Mobile MIM will have a safety guide and carry “sufficient labeling and safety features to mitigate the risk of poor image display due to improper screen luminance or lighting conditions,” circumstances that could contribute to a potential misdiagnosis or error.
“Establishing a diagnostic protocol for medical imaging is no simple matter for a device like the iPhone or iPad,” said CTO of MIM Software Inc., Mark Cain. “It is critical to understand the characteristics of the device and to establish methods and tools that are safe and effective, while working within those constraints. There has been a gap in the market for a remote imaging device like this, and now it can be filled."
Physicians can purchase Mobile MIM from the US Apple Store next week.
"There’s an app for that." is a trademark of Apple Inc. and a widely recognized marketing campaign slogan for the hundreds of thousands of applications available for the iPhone and iPad devices.
Nearly 1 in 4 Implanted Defibrillators are Unnecessary and Risky
A new study released today says 22.5% of implantable cardioverter-defibrillators (ICDs) are surgically implanted in patients who do not meet medical guidelines for these devices.
An implantable cardioverter-defibrillator (ICD) is a medical device about the size of a cookie implanted in the chest that detects an irregular heartbeat, an arrhythmia, and sends electrical shock to the heart to restore a normal rhythm.
Researchers studied 111,707 cases submitted to the National Cardiovascular Data Registry-ICD Registry between January 1, 2006, and June 30, 2009 and found that 25,145 patients, or 22.5%, given an ICD were non-evidence-based ICD patients, meaning they failed to meet medical criteria indicating use of an ICD.
While ICDs are effective in preventing sudden cardiac death in patients with advanced heart failure, they are not recommended in patients recovering from coronary artery bypass surgery or heart attack, or those recently diagnosed with heart failure.
Non-evidence-based ICD patients were more likely to be older, with diseases such as heart failure, atrial fibrillation or flutter, ischemic heart disease, cerebrovascular disease, chronic lung disease, diabetes and end-stage renal disease. They required a hospital stay three times longer and suffered a significantly increased risk of dying in the hospital than patients who did meet ICD guidelines.
The study called Non–Evidence-Based ICD Implantations in the United States appears in the January 5 issue of The Journal of the American Medical Association (JAMA).
“Clearly there is a lack of knowledge and a lack of awareness of the guidelines, and some patients were harmed,” said Sana Al-Khatib, lead researcher from the Duke Clinical Research Institute told Bloomberg.com. “More education is needed. Hopefully physicians will look at our results and reflect on their practices.”
ICD implant sales in the U.S. are 6.6 billion dollars a year, reports Bloomberg. An ICD implant procedure can cost more than $50,000.
Kids Swallowing Button Batteries Need Immediate Medical Attention, but 22% of Doctors May Mistreat
A new study has found that button batteries, also called disc batteries, lodged in the esophagus of children can do extensive damage within hours, worrying study authors because in an earlier study 22% of physicians said they would not remove such batteries even if lodged in the esophagus.
The study entitled A Review of Esophageal Disc Battery Ingestions and a Protocol for Management appears in the September 2010 issue of the Archives of Otolaryngology – Head & Neck Surgery.
As small consumer electronic devices, such as watches and hearing aids powered by button batteries become more prevalent in our lives, so do incidences of people ingesting the tiny batteries. According to the National Capital Poison Center, people of all ages swallow more than 3,500 button batteries every year in the United States. While most of these button batteries pass through the digestive system, those that hang up in the esophagus or elsewhere in the body can cause extensive damage.
In the study, researchers followed ten pediatric patients who ingested a button battery that lodged in the esophagus and required endoscopic retrieval. Seven of the children had severe esophageal damage. Two children suffered serious damage even though a physician removed the battery within three hours of ingestion.
"A disc battery is an increasingly common foreign body ingested by children," said Stanley J. Kimball, DO, lead researcher from Mount Carmel Health System in Columbus, OH. "There is significant morbidity when the battery is lodged in the esophagus. The physiologic damage is caused by leaking alkaline contents causing a liquefactive necrosis, electrical discharge leading to low-voltage burns, and pressure necrosis."
However, an article in the Los Angeles Times said that study researchers described another study in which a third of physicians said they were unconcerned about swallowed batteries. "Twenty-two percent would not remove even if they were lodged in the esophagus," researchers wrote.
Button batteries can also cause permanent injury if placed in the ear or nose.
Last week, popular Chuck E. Cheese’s Restaurant recalled more than one million children’s toys because the toy’s button batteries posed an ingestion hazard to children. There was one report of a child swallowing a battery and another inserted a battery into his nostril.
The National Capital Poison Center recommends you take these actions if you or someone you know swallows a button battery:
- Immediately call the 24-hour National Battery Ingestion Hotline at 202-625-3333 (call collect if necessary), or call your poison center at 1-800-222-1222.
- If readily available, provide the battery identification number, found on the package or from a matching battery.
- In most cases, an x-ray must be obtained right away to be sure that the battery has gone through the esophagus into the stomach. (If the battery remains in the esophagus, it must be removed immediately. Most batteries move on to the stomach and can be allowed to pass by themselves.) Based on the age of the patient and size of the battery, the National Battery Ingestion Hotline specialists can help you determine if an immediate x-ray is required.
- Don’t induce vomiting. Don’t eat or drink until the x-ray shows the battery is beyond the esophagus.
- Watch for fever, abdominal pain, vomiting or blood in the stools. Report these symptoms immediately.
- Check the stools until the battery has passed.
Your physician or the emergency room may call the National Button Battery Ingestion Hotline/National Capital Poison Center collect at 202-625-3333 for consultation about button batteries. Expert advice is available 24 hours a day, 7 days a week.
Hospital Circumcises Newborn Boy against Wishes of Family
A Miami hospital is facing legal action after circumcising a newborn boy after the family repeatedly expressed wishes that he remain intact, according to ABC News.
Vera Delgado is suing Baptist Health’s South Miami Hospital for the unauthorized circumcision of her 8-day-old son Mario Viera, who was in the neonatal intensive care unit suffering birth complications, after she had repeatedly told hospital staff that she did not want the baby circumcised because she is culturally against the procedure.
However, Delgado is not suing for medical malpractice. She is suing for assault and battery on the baby.
"We are suing for battery, an unauthorized assault on this baby,” said Spencer Aronfeld, Delgado’s attorney. “They took a knife to him without his parent’s permission.”
Circumcision is controversial, the practice of it or aversion to it embedded in certain religious and cultural ideals. Different sides of the medical community argue health benefits versus adverse side effects.
“Based on a review of medical and psychological literature and our own research and experience, we conclude that male circumcision causes serious, generally unrecognized harm and is not advisable,” the Circumcision Resource Center states its view. “Circumcision is a social and psychological issue that is disguised as a medical issue.”
“The baby’s circumcision was an unfortunate mistake caused by a misread consent form,” Fox News reports the hospital said in a statement. “As soon as the error was discovered, the doctor and nurses let the family know what had occurred. We also immediately implemented new processes to ensure this mistake will not occur again. The procedure itself was performed following appropriate surgical guidelines and the baby didn’t have any complications. Nevertheless, we’re all deeply sorry that this happened.”
V.A. hospital potentially exposed 1,812 Veterans to blood-borne diseases and HIV during dental work
A routine inspection has found that Cochran V.A. Medical Center in St. Louis, MO may have exposed more than 1,800 veterans to blood-borne diseases such as HIV, hepatitis B and hepatitis C during dental work, according to an article in The New York Times.
During the period when these veterans had dental work from February 1, 2009 to March 11, 2010, Cochran V.A. failed to follow V.A. procedures requiring the cleaning of medical instruments with a special detergent before sterilization.
The Department of Veterans Affairs sent letters to all 1,812 veterans notifying them of the exposure, saying that the risk of “infection was extremely low." The hospital is offering the veterans free blood test screening for HIV, hepatitis B and hepatitis C infection.
"This is absolutely unacceptable," said Missouri Congressman Russ Carnahan. "No veteran who has served and risked their life for this great Nation should have to worry about their personal safety when receiving much needed healthcare services from a Veterans Administration hospital."
Carnahan sent letters to President Obama and VA Secretary Eric Shinseki, insisting they immediately investigate this indefensible breach of standard operating procedures and report back what will be done to remedy the issue and ensure that it never occurs again. Carnahan also contacted House Veterans Committee Chairman Bob Filner to schedule a hearing quickly to look into the matter.
I can only imagine the horror and anger our veterans must be feeling after receiving this letter," Carnahan added. "They have every right to be angry. So am I."
Extent of Echocardiogram Backlog Debacle at NYC’s Harlem Hospital Grows
Doctors reviewing the backlog of thousands of echocardiograms performed at New York City’s Harlem Hospital found there are substantially more of the unread tests than previously thought and they span a period years longer, said an article yesterday by The New York Times.
An echocardiogram is a test that uses sound waves to create a picture of the heart. The test shows the size and shape of the patient’s heart, as well as the organ’s function. When viewing this test, a doctor looks for health conditions such as physical damage or abnormalities, impaired function, infection, possible blood clots inside the heart, fluid buildup in the pericardium (the sac around the heart), and problems with the aorta.
A routine record review last month by Columbia University, who provides doctors to the New York City Health and Hospitals Corporation (HHC) through an affiliate program, found the backlog of patient’s heart tests and notified the company on May 20. They determined that although the patient’s heart tests had been viewed by a technician, they had never been reviewed by a cardiologist.
On May 25, a joint press release by NYC Health and Hospitals Corporation and Columbia University Medical School announced that the backlog contained about 4,000 echocardiograms performed between 2007 and 2010.
Physicians at Harlem Hospital were apparently aware of the backlog and had requested more staff from hospital administrators. The backlog of tests perpetuated because physicians at the hospital used a policy allowing technicians to review and prioritize the tests, alerting physicians to those the technician deemed abnormal first, the rest falling by the wayside.
"While the process the doctors followed may have alerted cardiologists to those echocardiograms that were most likely to be abnormal, the failure to read echocardiograms in a timely manner is inexcusable and may have placed patients at risk," said HHC President Alan D. Aviles. "As our team of cardiologists continues to review every pending echocardiogram, we will take immediate action to locate any patient that may be in need of follow-up care."
The investigation has now revealed that the test backlog extends as far back as 2005 and numbers 1,000 more than previously thought, totaling about 5,000. Doctors are also re-reviewing an additional 2,000 tests that doctors read and made notes in the medical records but never signed them, as required by medical protocol.
200 of the patients whose echocardiograms went unread have since died and investigators are trying to determine if these deaths were avoidable had the tests been properly handled.
According to The New York Times, the investigation has, “found six patients who might have been deprived of necessary medical treatment because the results of their heart tests were not read by doctors.”
Ana Marengo, a spokesperson for the city’s Health and Hospitals Corporation, told the newspaper that the hospital has attempted contact with all six patient, resulting in three patients who have seen a cardiologist, two patients with appointments to do so, and one who has been unreachable.
The New York City Health and Hospitals Corporation (HHC) is only notifying those patients whose test review shows an immediate need for medical attention. The rest of the 5,000 patients will only learn their test was in question when the hospital corporation sends out a letter of reassurance after the review is completed.
Neuromuscular Blocking Agents Wrong-Drug Errors at PA Medical Facilities
The Pennsylvania Patient Safety Authority released a report in its December 2009 Patient Advisory regarding wrong-drug errors of neuromuscular blocking agents at Pennsylvania medical facilities.
Patients are administered neuromuscular blocking agents (NMBAs) in emergency departments, intensive care units, interventional radiology areas and medical and surgical units to paralyze skeletal muscles during surgery conducted under general anesthesia and for patients requiring intubation for airway management. The drug renders patients unable to move or breathe and can be especially dangerous if administered to a patient not properly ventilated. They do not affect the patient’s level of consciousness, anxiety or ability to feel pain.
NMBAs are considered high alert medications because their misuse has the potential to cause catastrophic injuries or death. They should only be administered in a facility with proper equipment for intubation and oxygen administration and personnel trained to perform respiratory support and airway maintenance.
The Authority received 154 reports of medication errors involving NMBAs from Pennsylvania healthcare facilities between June 2004 and June 8, 2009. 77.9% of these reported events actually reached the patient and 9.1% resulted in harm to the patient, which rate of occurrence is nearly 13 times greater when compared to the rate of 0.7% for all medication errors reported to the Authority in that time period.
One instance of a NMBA wrong drug error included in the Authorities report:
A patient was admitted for a planned surgery. While in holding area of the OR prior to surgery, anesthesia staff started an IV [intravenous] infusion and administered what they thought was midazolam [Versed®] 1.6 mg IV. The patient immediately began flailing and reaching up to her face, and she became apneic. Ambu bag ventilation was initiated, and pulse ox was placed and was 90%. The patient was taken to the OR to be ventilated and monitored until patient awoke (approximately five minutes). The patient described being awake and paralyzed with vivid recollection.
Wrong drug errors involving NMBAs or any other medication may have contributing factors such as unsafe storage, similar product labeling or packaging, look-alike drug names or unlabeled syringes. The Authority outlined several risk reduction strategies to prevent wrong drug errors involving NMBAs including separate storage, warning labels, limiting access by dispensing NMBAs only from the pharmacy and computer reminders for the pharmacy to verify ventilatory assistance before dispensing the drug.
Some of the most common forms of hospital negligence include wrong-site surgeries, medication errors, surgical errors, development of hospital-acquired infections, improper use of anesthesia, improper treatment of a diagnosed medical condition, failure to monitor or stabilize a patient, or improper use of a medical device. Hospital negligence can result in serious injuries and even deaths. If you have been injured as the result of negligence while you were a patient in a hospital, or if a loved one died due to hospital negligence, you may be able to file a claim and collect compensation for pain and suffering, lost wages, medical expenses and other losses. Call Napoli Bern Ripka, LLP at 888-529-4669 today to discuss your legal options
Philly Man Having Heart Attack Dies Awaiting Treatment in Hospital ER then Robbed by Drug Addicts
A popular Philly local musician and high school counselor went to a hospital emergency room on Saturday complaining of heart attack symptoms. He sat untreated in the waiting room for 80 minutes, where he died and three homeless drug addicts robbed him of his wristwatch.
Joaquin Rivera, 63, of Frankford, walked two blocks from his home on Duffield Street to the emergency room of Atria Health’s Frankford Campus in Northeast Philadelphia, where he checked in at 10:45 p.m. complaining of pain shooting from his left arm to his chest. He took a seat in the waiting room as a nurse instructed.
At 11:00 p.m., Richard Alten, 44, signed in for treatment at the emergency room and he, along with another man and woman companion, take a seat in the waiting room. The three conversed with Rivera.
According to witnesses, police believe Rivera lapsed into unconsciousness about an hour after checking in. All caught on the hospital’s security video, one of the three people he had spoken with in the waiting room then removed Rivera’s watch and briefly passed it to Alten. Alten was then called to see ER doctors and his companions left.
Around 11:45 p.m., a witness alerted hospital security that Rivera appeared to be dead and of the robbery.
“There’s no resistance from Mr. Rivera at all, which is why we believe he’s probably dead. There’s no stirring from him,” said Capt. Jack McGinnis, a city detective, of the security video.
Police took Richard Alten into custody. The other suspects, a black woman in her thirties and 5-foot-8 black man in dark pants who limped are wanted by police. McGinnis describes the three suspects as homeless drug addicts. Police say they may release hospital security video in hopes of catching the other two suspects.
Rivera was pronounced dead At 12:04 a.m., one hour and 19 minutes after arriving at the hospital.
“My father went there complaining about chest pains,” Joaquin Rivera Jr., 25, said. “They made him wait there for over an hour. That is ridiculous. I feel like the hospital killed him. “
Joaquin Rivera was a popular folk musician in Philly, especially within the Puerto Rican community. He was a bilingual counselor at Olney High School and worked for the school district 36 years.
Funeral Mass for Joaquin Rivera will be at 10 a.m. Saturday at Christ Church and St. Ambrose, 600 W. Venango St. Friends may call at 6 p.m. Friday at the John F. Givnish Funeral Home, 10975 Academy Road, and at 9 a.m. at the church. Burial will be in Greenmount Cemetery, Front and Luzerne streets.
Aria Frankford Hospital has released the following statement:
“Due to the pending criminal investigation and citing patient confidentiality, Aria Health is unable to comment with regards to the circumstances surrounding this patient’s death. Aria Health is cooperating fully with the Philadelphia Police Department in connection with the investigation and offers its condolences to the patient’s family. Aria officials are conducting an intensive internal investigation into this event and are coordinating their efforts with law enforcement.”
Hospital negligence can result in serious injuries and even deaths. If you have been injured as the result of negligence while you were a patient in a hospital, or if a loved one died due to hospital negligence, you may be able to file a claim and collect compensation for pain and suffering, lost wages, medical expenses and other losses. Some of the most common forms of hospital negligence include wrong-site surgeries, medication errors, surgical errors, development of hospital-acquired infections, improper use of anesthesia, improper treatment of a diagnosed medical condition, failure to monitor or stabilize a patient, or improper use of a medical device. Call Napoli Bern Ripka, LLP at 888-529-4669 today to discuss your legal options.
