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Tue January 25, 2011
Investigators fault ambulance teams at Seattle Children’s
A nurse may have contributed to a baby’s death, during transport to Seattle Children’s Hospital last September, according to investigators from the Washington Department of Health (DOH). An earlier autopsy said the baby died from natural causes, but state investigators are not convinced. They also say the hospital must improve how it monitors medications in ambulances.
"The four-month investigation by the state Department of Health concluded the hospital didn’t meet a legal requirement that only authorized practitioners may issue orders 'for all drugs, intravenous solutions, blood, medical treatments, and nutrition.'"
The investigation began while three other cases involving deaths or harm at Seattle Children’s Hospital were also under review. In those other cases, the DOH concluded the hospital’s safety measures were perfectly adequate.
How the baby died
Seattle Children's Hospital has its own custom-built ambulance to transport babies and children between hospitals. In the case at issue, the ambulance went to Evergreen Hospital in Kirkland to pickup a newborn baby girl. The baby went into cardiac arrest, before the ambulance left Evergreen, and a nurse with the ambulance team administered four drugs -- without first getting a physician's orders:
- epinephrine [a drug used to regulate heart rate],
- morphine [a pain reliever],
- ativan [an anti-anxiety medication] and
- vecuronium [a paralytic]
The baby died. These facts are not disputed. An autopsy, by the King County Medical Examiner, concluded the death was from natural causes, largely due to malformations at birth. But, the Department of Health says there’s no way to rule out whether the drugs played a role. Seattle Children’s issued a written statement rejecting any responsibility for the death:
"We strongly disagree with the Washington State Department of Health’s (DOH) characterization of this patient’s cause of death."
Second conclusion: System problem at Children's
Donn Moyer with the Washington Department of Health says investigators wanted to know if this was a problem with an individual nurse, or a bigger system problem. Investigators chose 12 out of 28 ambulance transport cases from last September, and started asking questions.
"And it turned out that in every case we examined in September, the transport teams' nurses were giving medications and could not document they had gotten a doctor's orders," says Moyer.
Seattle Children's statement says the problem was primarily with one nurse, who is currently under a separate investigation. The DOH says multiple nurses violated the same rule, even if nobody was harmed.
The hospital says it is complying with an order to improve its supervision of medications in ambulances.
Federal officials, from the Centers for Medicare and Medicaid Services, are also looking into how the hospital monitors medications on its ambulances.
Medication errors are among the most common mistakes at hospitals, and it's up to hospitals to reveal their own mistakes to regulators. In October, Seattle Children's held a one-day, all-staff workshop to improve how drugs are handled and administered -- and prevent future mistakes.