Articles Posted in Hospital Errors

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A proposed Illinois law would limit the number of patients each hospital nurse would be allowed to care for at one time. The proposed legislation was based on a national survey, which suggested that such a rule would lead to better working conditions for nurses and would benefit patient care.

However, Illinois’ leading hospital lobbying group remained solidly opposed to the idea, arguing it would result in the closure of many hospitals, especially in less populated rural areas, and would accelerate the already rising costs of healthcare.

The survey was conducted in 2018 by the group Nurses Take DC, a national organization that lobbies for stricter nurse-to-patient ratios.
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Rodney Knoepfle, 67, suffered from significant health problems. He had a history of stroke and orthopedic and cardiac problems. Before all this took place, he executed an advance directive, which designated his wife to make healthcare decisions and stated his desire to forego life-sustaining healthcare treatment should that become necessary. In other words, he signed this directive stating that he did not wish to be resuscitated in case of a deteriorating medical condition.

When Knoepfle began feeling poorly, he was admitted to St. Peter’s Hospital. He provided his advanced directive to the nurses and staff who entered a do-not-resuscitate (DNR) order into the hospital computer system.

However, two days later, Knoepfle became non-responsive, prompting a nurse to call for help. When no one responded to the call, the nurse called a code. The on-duty hospitalist, Dr. Lee Harrison, came to Knoepfle’s bedside and performed chest compressions for 10 to 15 minutes. Knoepfle was resuscitated; however, he then coded the following day. Dr. Harrison then gave Knoepfle adrenaline.
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Hospital-borne infections have been a problem for years, and drug-resistant bacteria like MRSA (Methicillin-resistant Staphylococcus aureus) have become household names. However, a New York Times article highlights another virus that is causing a high rate of death among children and the elderly. The article provides some insight into how the medical community could help decrease the number of deaths.

Norovirus is an extremely contagious virus and in recent years has become the leading cause of acute gastroenteritis. And while many of the symptoms caused by norovirus mimic that of the flu or a severe cold, e.g. nausea, vomiting, diarrhea, and stomach pain; epidemiologist Aron Hall warns, “I think there is perhaps a misperception that norovirus causes a mild illness; . . . [it is] a major problem that requires some attention.”

According to the Centers for Disease Control and Prevention (CDC), each year norovirus causes over 20 million illnesses, leads to 70,000 hospitalizations, and results in 800 deaths. In addition, norovirus is the most common cause of food disease outbreaks in the U.S. Because norovirus has much in common with C. difficile, a bacterial infection, medical officials are examining the ways hospitals and nursing homes have tried to combat the spread of C. diff to try and help reduce the spread of norovirus.
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Connie Lockhart was hospitalized after overdosing on medication. She was 58 years old at the time of this incident. An emergency room physician inserted a central line femoral catheter in her right leg. However, this was misplaced into her femoral artery instead of her femoral vein.

Lockhart was transferred to the facility’s ICU where she received care from critical care pulmonologist Dr. Sachin Lavania.

Nurses informed Dr. Lavania that Lockhart’s leg had become cold, mottled, and pulseless.
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Anita Irvin went into the emergency room complaining of swelling and pain in her leg. During that visit, her primary care physician informed the emergency-room physician that she had recently made suicidal ideations.

The emergency-room staff prevented Irvin from leaving the hospital, dressed her in a paper hospital gown, and forced her to turn over her purse and provide blood and urine samples before a counselor could be called to evaluate her.

Irvin sued the hospital for false imprisonment.
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Linda Shelly, 56, suffered from various health problems including hypertension, congestive heart failure and diabetes. When she experienced shortness of breath, she was admitted to a local hospital, where a CT scan revealed a retroperitoneal cyst.

The next day, Dr. Muthiah Thangavelu, a general surgeon, performed surgery to remove the cyst. A subsequent pathology report showed that a portion of Shelly’s ureter was removed during the surgery and was included with the frozen section of the cyst. She was later diagnosed as having a right ureteral injury, a urinoma, and kidney swelling. Urinoma is the result of a breach of the integrity of the pelvis or calices of the kidney or of the ureter. Urinomas are urine collections usually found in the retroperitoneum, most commonly in the perirenal space, as a result of renal tract leakage caused by urinary obstruction, trauma or post-surgery complications.

Despite attempts to save her ureter and kidney over the next two years, she lost a kidney, necessitating dialysis and hastening her death. She was survived by her three adult children.
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Bradley Metts, who was 9 years old at the time of this incident, was evaluated for severe ear pain by his primary care physician at University Medical Associates. Eight days after the evaluation, Bradley’s condition deteriorated; he developed headache, nausea, vomiting and photophobia. Bradley returned to the clinic where a nurse practitioner described him as being acutely ill.

The medical provider at the clinic ordered various STAT (immediate) blood tests, including an erythrocyte sedimentation rate test and a C-reactive protein test.

Although the lab samples were sent to Athens Medical Laboratory by the mid-afternoon, the results, which were markedly elevated, were not returned for six days.
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Keimoneia Redish was a 40-year-old mother of five who suffered from asthma. When she experienced breathing difficulties, her partner took her to a hospital emergency department. Testing there showed that her carbon dioxide level was above normal at 57 mmol/L and that her pH level was 7.28, which is below normal and indicated mild hypercapnia and acidosis. Hypercapnia is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Acidosis is a condition in the blood that causes the pH level to fall below the normal limit of 7.35.

Although steroids and other treatments over several hours were administered, Redish’s condition did not improve. She was admitted to the hospital’s intensive care unit, where an attending physician intubated her and placed her on a mechanical ventilator.

Her carbon dioxide level and pH remained stable but still out of range of normal. A pulmonologist later examined Redish and recommended that she continue the ventilator but also add Ketamine, which is a medication mainly used for starting and maintaining anesthesia. The pulmonologist indicated that if Redish’s condition did not improve, general anesthesia to relieve her bronchospasms would be recommended.
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LaQuinta Murray experienced severe pain in her lower extremities. She was just 29 years old at the time. She was admitted to Centennial Hills Hospital Medical Center with a diagnosis of sickle cell crisis, chronic anemia and strep throat. Dr. Mandip Arora ordered both opioid and non-opioid analgesics, as well as strict recording of Murray’s urine output.

Over the next four days, Murray was administered Toradol. She experienced critically high potassium levels and decreased urine output, but the nurses chose not to record this.

Murray then suffered renal failure, which led to fatal cardiac arrest. Murray had been a CNA. She was survived by her husband and minor child.
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Dolores Madigan, 71, had a seizure disorder. She took the anticonvulsant medications Keppra and Dilantin daily.

When she was admitted to Brookhaven Memorial Hospital Medical Center, she was suffering from an eye infection. Internal medicine physician Dr. Jayeshkumar Makavana ordered swallow testing to rule out a stroke. Although Dr. Makavana discontinued Madigan’s medication, a neurologist later reinstated the anticonvulsants.

The next night, a nurse alerted Dr. Makavana that Madigan had not been receiving her medicine. The nurse then administered a small inadequate dose of medication in line with Dr. Makavana’s instructions.
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