LEXINGTON, Ky. (LEX 18) — Last summer, an 81-year-old man was transferred to CHI Saint Joseph Health Main in Lexington. Within 48 hours, he was dead.
The man was sent to the Lexington hospital because of a gastrointestinal bleed requiring a higher care level. But it was a medication mix-up that caused his death, according to a coroner's report.
LEX 18 began looking into what happened months ago and recently obtained documents from a Kentucky Board of Nursing investigation into what happened.
The Fayette County coroner's report states that the man died from "complications of inadvertent administration (Naturalyte) in the setting of gastrointestinal hemorrhage."
The nursing board's investigation into one of the nurses involved in the mix-up describes a series of events that led to the patient being mistakenly given Naturalyte, a dialysis liquid, instead of a colonoscopy prep called GoLytely.
"Multiple process failures."
Nursing board executive director Kelly Jenkins was limited on what she could say about this specific case but told LEX 18 that fatal medication errors are very rare.
"When you go back and you look at all the steps leading from the time they got the order to give the medication to the time it actually hit the patient, there were process failures," Jenkins said. "Multiple process failures."
While LEX 18 has not seen photographs of the exact medication containers in this incident, available images of jugs of Naturalyte and GoLytely show similarities.
One expert LEX 18 spoke to questioned why the Naturalyte, which isn't made to be ingested, was available in the ICU.
A letter written to the nursing board by the nurse's attorney states that the dialysis team left the dialysis liquid behind on the ICU floor and could have been there for up to three days.
As a safety precaution, nurses have to scan barcodes on patients' wristbands and then scan the medication they're about to administer to ensure that the correct patient gets the correct medication in the right dose, Jenkins said.
In this case, the dialysis liquid, considered the colonoscopy prep medication, would not scan. The nurse called the hospital pharmacy at about 5:35 p.m. on June 30, 2022, and informed them that the jug would not scan.
Rather than sending new medication or coming up to see the jug in question, the pharmacy sent a label to the ICU floor through a tube system that is used to send and receive medication and supplies, according to the attorney's letter. A timeline in the nursing board's file says that the label was sent about 5 minutes after the nurse called.
The nurse gave the patient about 8 oz. of the Naturalyte, believed to be GoLytely, before the end of her shift, her attorney wrote in the letter. A timeline in the file notes that the patient was "unable to tolerate" the liquid.
The doctor who'd initially ordered that the patient be given colonoscopy prep said that the patient had to take the full amount ordered, according to the timeline and attorney's letter.
After the first nurse left for the evening, another nurse gave the patient the rest of the liquid through a feeding bag, according to the attorney's letter. According to the timeline, the medication mix-up was caught at about midnight, and the patient died at about 7:35 the following morning.
The letter from the nurse's attorney to the board also noted that she had been caring for three ICU patients at the time of the incident – more patients than she usually would have been caring for as the charge nurse on the shift.
The letter states that three nurses had been pulled from the ICU that shift to work on another unit. When the patient who ultimately died was transferred to the hospital, she took him on as a third patient.
Because of the multiple process failures that reportedly happened outside of her role, the nurse in question was not disciplined by the nursing board over what happened. In the letter to the nurse, the nursing board voiced concern that she had not visually double-checked the medication's label before administering it.
Medication Mix-ups
LEX 18 spoke to The Ohio State University Wexner Medical Center's medication safety officer, Joseph Melucci, to learn more about medication mix-ups.
Melucci acknowledged that the complexities of healthcare and the urgency often required can contribute to mistakes. That's why technology and fail-safes are in place to help staff slow down and avoid mistakes.
"Those pauses are intended to be important stops to look at the situation and maybe re-do or perhaps for the first time do some validation steps that maybe weren't done previously," Melucci said.
While technology is used to help prevent mistakes, it can lead to a level of over-reliance and complacency, both Melucci and Jenkins said.
"There's nothing like the human mind to evaluate the state of circumstances when you're about to do something that's risky for a patient," Melucci said.
"Those are things that are taught in our great nursing schools here in the commonwealth, and you've got to keep your basics," Jenkins said. "Even though you are using technology, because technology – there can be process failures even with the technology."
"Some assumptions made."
In the Saint Joseph case, Melucci said it appeared that a workaround was used when the barcode didn't scan.
"There were some assumptions made in this case that I'd consider to be unsafe," Melucci said.
According to the nursing board's investigative file, the nurse involved in the Saint Joseph incident attended training on how to avoid medication errors after the incident. She was recognized just weeks later for catching another potentially fatal medication mix-up before that medication ever reached the patient, according to documents in the file.
"I hope that many people learn from this mistake and the risks of giving medication and working around barcode scanning, that those risks are heightened and sensitized by this particular event," Melucci told LEX 18. "I hope your report accomplishes that."
CHI Saint Joseph Health declined LEX 18's request for comment on the situation, saying instead that it "honors the privacy of its patients and does not release information regarding their care and treatment. Additionally, in agreement with the family of the patient you referenced, CHI Saint Joseph Health will not disclose or otherwise make a comment in response to your request."
The Kentucky Board of Pharmacy is still investigating the incident.
