Nurse Gives Patient Paralytic Instead of Antacid

By CHRISTINA CARON Los Angeles Times Nov. 21, 2011

The family of a 79-year-old dialysis patient is suing a Florida nurse who accidentally gave him a deadly dose of a drug that induces paralysis, instead of an antacid. "The hospital killed my dad," said Marc Smith of Miami, Fla., whose father went into cardiac arrest after the nurse's mistake at North Shore Medical Center in Miami. Richard Smith, who had a history of kidney disease, had been admitted to the ICU after a dialysis session where he experienced severe shortness of breath. The next day, July 30, 2010, he complained of an upset stomach, so the doctor prescribed the antacid. Marc Smith came by to visit that morning, and found his dad "unconscious, unresponsive and on a respirator." "The nurse said my dad had coded. I said, 'He coded? When did that happen?'" Smith looked at his dad's chart, and found his father had been resuscitated about 10 minutes earlier. "The nurse basically told me, 'Talk to the doctor," Marc Smith said. When he did, he says, the doctor told him, "I'm sorry to have to tell you this but the nurse administered the wrong medication and sent your dad into respiratory arrest." "He said the packaging looked the same and he grabbed the wrong package," Marc Smith recalled. Uvo Ologboride, the nurse named in the lawsuit, had given Smith pancuronium. The drug, which is typically used during intubations, acts as a muscle relaxant and paralytic. In higher doses, pancuronium is used to administer lethal injections. Thirty minutes later, Smith was found unresponsive. Although doctors were able to revive Richard Smith, he was brain dead. He remained in a vegetative state until he died a month later. The Smith family lawyer, Andrew Yaffa, told ABCNews.com, "This is the worst case of medical neglect I have ever seen." Yaffa, who said he's handled hundreds of hospital death cases in his 22 years as a lawyer, added, "The hospital just seems to be thumbing their nose to this family." The nurse who administered the incorrect medication "is still working there in the exact same unit where the medical error occurred," Yaffa said.

Ologboride, who could not be reached by ABCNews.com, has been retrained, and fined, according to ABC News Miami affiliate WPLG. In addition, the hospital has since removed pancuronium from all nursing areas except for the operation room, where the medication will only be handled by anesthesiologists. But that's little consolation for Marc Smith, an EMT, who says, "if we administer the wrong medication and someone dies, that's negligence. That's murder." The stress has taken its toll on his mother, he said, who was married to Richard Smith for 55 years. "For the most part, she's making it," he said. The elderly couple had recently taken in two children, a 2 year old and a 10 year old whose parents had died. Ever since Marc Smith was a boy, "My mother and father had taken in a countless number of children who were in bad situations at home or didn't have place to stay," he said. "They did it on a teacher's salary, but we never wanted for anything growing up." A report from the Florida Agency for Health Care Administration demonstrated that with all the safeguards in place to prevent a patient from receiving the wrong medication, the nurse would have had to ignore nearly all of the protocol in place for administering drugs. Specifically, the nurse "failed to look and read what medication he was taking failed to scan to determine the right count for the medication, failed to match the patient's ID with the scanned medication." In addition, the report says, the pharmacy wasn't able to show any justification for storing pancuronium in that particular area of the hospital. The Smith family originally filed a wrongful death lawsuit in February against the hospital's parent company and the pharmacist, but they recently amended their complaint to include the nurse and the hospital. They now claim the nurse not only administered the wrong medicine, but also failed to properly monitor Richard Smith. "We learned that the nurse who administered the medication had left the room for 30 minutes," Marc Smith said. The family is seeking compensation for funeral expenses, medical expenses, and damages resulting from mental pain and suffering. "From our understanding, [my father] wasn't hooked up to alarms, or if he was, nobody was there to hear them," he said. "The hospital basically suffocated my dad and he was sitting there alive when the medication was first given to him and couldn't move because he was paralyzed. He couldn't call out for help, he couldn't push a button. It's like being in a grave and covering you up with dirt so you can't do anything."

The North Shore Medical Center did not respond to inquiries from ABCNews.com prior to the publication of this article. The hospital did, however, issue a statement to WPLG, saying: "Our hearts go out to the Smith family for their loss. This was a tragic event which we immediately self-reported to the Agency for Health Care Administration. We conducted an internal review and have several new processes in place to ensure a situation like this does not happen again." Prior to the accident, Marc Smith said his father lived independently with his wife. He used a walker, but he was still active and "he did what he wanted to do." The day before the pancuronium was administered, Marc Smith described his father as "alert." "His only complaint to me was he was cold and his mouth was dry, which is not uncommon for dialysis patients," he said. Richard Smith, a retired PE teacher, had been an athlete "all of his life," said his son, one of his parent's two living children. "He led a very active life, he was an avid fisherman, he liked to cook. He trained deacons in the church." Now the Smith family said they are looking for closure, and hope to prevent other families from going through a similar experience. "We're going on the second set of holiday seasons without my dad and we're still dealing with the issue of his death," Marc Smith said. "Basically we don't want this to happen to anyone else.

Quaids recall twins' drug overdose

By CHARLES ORNSTEIN Los Angeles Times Jan. 15, 2008

Before actor Dennis Quaid went to bed Nov. 18, he gave one last call to Cedars-Sinai Medical Center, where his newborn twins were being treated for staph infections. "Oh, they're fine," Quaid recalled a nurse telling him about 9 p.m. "They're just fine." Actually, they weren't. Earlier that day, nurses had mistakenly given Thomas Boone and Zoe Grace 1,000 times the recommended dose of the blood thinner heparin. About two hours before Quaid's call, nurses had noticed Zoe oozing blood from an intravenous site on her arm and a spot on her heel, state records show. But that night, even as hospital staff scrambled to reverse the effects of the heparin, Quaid said, no one notified him or his wife, Kimberly, of the crisis. The first that Dennis Quaid learned of the medication error was at 6:30 a.m. the next day, he said, when he arrived at the Los Angeles hospital. Treatment decisions had been made without them, he said. "Our kids could have been dying, and we wouldn't have been able to come down to the hospital to say goodbye," Dennis Quaid said in a 90-minute interview Monday, the couple's first since the overdose. At the door of the children's hospital room, he said, he was greeted not just by a pediatrician and a nurse but by a representative of the hospital's risk management department. A heparin overdose had left the twins' blood too thin to clot, Quaid said he was told, leaving the premature infants vulnerable to uncontrollable bleeding. They had been given an antidote. The Quaids said they spent the day watching in terror as doctors and nurses hovered over their critically ill children. At one point, as a bandage was being changed, blood spurted from the area around Thomas' clipped umbilical cord and hit a wall about 5 feet away, Dennis Quaid, 53, remembered. "They were in incubators with cords attached to them and monitors, and you could barely hold them," said Kimberly Quaid, 36. "Every time you'd move them, the alarms would sound. . . . The stress was overwhelming." The Quaids said they felt betrayed and misled by Cedars-Sinai, one of the nation's most prestigious hospitals. And their anger has only grown since the release last week of a report by state regulators, who found that Cedars-Sinai had placed the Quaid twins and others in immediate jeopardy by its improper handling of medication.

The Quaids said they believe someone at the hospital leaked information about the error to the news media. Their own family members, they said, learned that the babies were in the hospital only after the website TMZ.com broke the news Nov. 20, two days after the heparin overdose. They said they made a deliberate decision not to tell relatives or friends that their children were in the hospital, because they didn't want to worry them and because they did not want the information to appear in tabloid reports. "We were told that it was not a big deal," Kimberly Quaid said. "We figured we'd be home in a couple days and nobody would know any different. That wasn't the case." Cedars-Sinai spokesman Richard Elbaum declined to comment on most of the allegations made by the Quaids. "Throughout the course of their children's hospitalization and continuing today, we have reached out to the Quaids to discuss any concerns or questions they have," he said. "We would like to continue to discuss all of these and any other concerns directly with the Quaids to identify and resolve any questions." Elbaum did say the hospital is investigating whether there was a violation of the twins' privacy rights by leaks to the media. "We take very seriously any allegations of breaches of patient confidentiality and investigate these in a comprehensive manner," he said. The Quaids have already filed a lawsuit against Baxter Healthcare Corp., one of the manufacturers of heparin, contending that the labeling and design of the product led to the error. Baxter representatives have said the error resulted from improper use, not the drug itself.