Hospital details what went wrong: Woman dies from toxic injection

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Thursday, November 25, 2004, 12:37 A.M. Pacific

 

Hospital details what went wrong: Woman dies from toxic injection

http://seattletimes.nwsource.com/html/localnews/2002100635_deathfolo25m.html

 

By Nick Perry and Carol M. Ostrom

Seattle Times staff reporters

 

A Seattle hospital's recent decision to switch antiseptics from a brown

solution to a colorless liquid appears to have played a key role in the

death of an Everett woman.

 

Mary McClinton, 69, a tireless worker for the disadvantaged, died early

Tuesday. She was mistakenly injected with antiseptic — rather than a

marker dye — during a brain-aneurysm procedure at Virginia Mason Medical

Center 19 days earlier, on Nov. 4.

 

The hospital this week took the unusual step of publicly explaining, and

apologizing for, the error.

 

Exactly what went wrong during the aneurysm procedure is detailed in a

staff memo obtained by The Seattle Times. The memo, written by Dr. Mindy

Cooper, chair of the quality-assurance committee, and Robert

Mecklenburg, chief of the department of medicine, was sent to staff a

week after the surgery, 12 days before McClinton died.

 

" The solution used to clean skin before and after procedures was

recently changed from a brown iodine-based solution to a colorless

antiseptic, " which looks " exactly the same " as the dye, the memo states.

 

 

Mary McClinton was injected with an antiseptic.

" At some time during the procedure, the clear antiseptic solution was

placed in an unlabeled cup identical to that used to hold the marker dye

.... that is injected into blood vessels to make them visible on x-rays. "

 

The antiseptic then was injected into a main artery carrying blood to

the leg, the memo says.

 

" The antiseptic solution is highly toxic when injected into a blood

vessel. Acute and severe chemical injury to the blood vessels of the leg

blocked blood flow to muscles, causing profound injury and swelling of

the leg, " the memo states. " Kidney failure, a sudden drop in blood

pressure and a stroke followed. "

 

The memo called the medical error a " systems problem, " and while no

individual is responsible, " all of us " are responsible. " We have injured

her so badly that she may never again regain the life she enjoyed, " the

memo states.

 

As McClinton's condition worsened, hospital staff took drastic measures

to try to save her, including amputating one of her legs below the knee.

But her organs were too badly damaged.

 

Steven McClinton said his mother called two hours after the surgery

saying " something is very wrong. " He visited that night, and she was in

pain, her leg badly swollen, he said.

 

The family camped out at the hospital watching over her, said another

son, Gerald McClinton. At one point in the days following the surgery,

she mouthed: " I love you " before slipping into an incoherent state from

which she never fully recovered, Gerald McClinton said. He said he was

holding her hand when she died.

 

Hit by picture

 

Gerald McClinton said his mother may never have known she had an

aneurysm save for an odd incident at Virginia Mason two or three months

earlier.

 

She was there for an eye procedure, and as she was sitting in a waiting

room, a large picture, about 6 feet square, fell onto her head, the son

said.

 

His mother told him that the picture " knocked her silly, " Gerald

McClinton said. In the days afterward she felt dizzy, so he took her to

an Everett hospital where a brain scan revealed the aneurysm.

 

A Virginia Mason spokeswoman said last night the family " certainly are a

credible source " but she could not verify the picture incident.

 

Mary McClinton, who moved from Alaska in 1996, dedicated her life to

helping others, her family said. She was even adopted by the Tlingit

tribe for her work as a vocational coordinator.

 

She worked at the Greater Trinity Missionary Baptist Church in Everett

helping to find jobs for people with physical and mental disabilities,

said Pastor Paul Stoot Sr.

 

" Oh man, she was a mother to everyone, " Stoot said. " Everybody to her

was somebody that needed love. "

 

Her funeral will be held at noon Saturday at the Everett church, the

pastor said.

 

" Culture of patient safety "

 

Virginia Mason's unusual apology, posted on its Web site Tuesday, is

part of a " culture of patient safety " that has been cultivated at the

medical center since the patient-safety movement swept the country in

1999, said Dr. Robert Caplan, who heads the hospital's patient-safety

efforts.

 

" We just can't say how appalled we are at ourselves and the suffering of

this patient and her family and friends, " Caplan said yesterday. " We're

trying in every way we can to convey our apologies to this patient for

this preventable medical error. In many ways, this open and honest

communication is our way of trying to honor her. "

 

The only way to improve patient safety, he said, is to be " open and

honest about our errors. ... You can't understand something you hide. "

 

Since the error, the liquid antiseptic has been removed from the

hospital and replaced with a swab on a stick.

 

The hospital's public mea culpa is part of a broader trend of " trying to

be more transparent when there's been a harmful medical error, " said Dr.

Thomas Gallagher, a University of Washington internist who has studied

apologies and medical errors.

 

Gerald McClinton said the doctors treated his family well, and he is

glad the hospital did not try to hide the mistake.

 

" It's a mistake, a very preventable mistake, " McClinton said. " I am

getting angrier by the minute, although I don't know really who I should

be getting angry at. "

 

McClinton said his family has not contacted an attorney. The hospital

has approached the family wanting to talk about a settlement, he added,

although no meetings have taken place. " We are looking at our options at

this point, " he said.

 

Deanna Whitman, a spokeswoman for the Washington state Department of

Health, said Virginia Mason had reported more " adverse events " over the

past three years than three other Seattle hospitals — although she added

that she thinks Virginia Mason is generally more conscientious about

reporting such incidents.

 

" Adverse events " are mistakes that stem from systematic problems. Not

all medical errors are included.

 

Since the start of 2002, Virginia Mason, licensed for 336 beds, has

reported nine adverse events, including four that resulted in the

patient dying or being left in a permanent vegetative state, Whitman said.

 

During the same period, Swedish Medical Center, with 1,400 beds,

reported four incidents and no deaths. Harborview Medical Center,

licensed for 413 beds, reported five incidents including three that were

catastrophic.

 

The University of Washington Medical Center, with 450 beds, reported

seven incidents including three that were catastrophic, Whitman said.

 

Nick Perry: 206-515-5639 or nperry; Carol M. Ostrom:

206-464-2249 or costrom