Chemo Overdose Result of Illegible PrescriptionApr 26, 2005 | San Francisco Examiner It was a doctor's illegible handwritten prescription that triggered a lethal chemotherapy overdose that ended the life of a 41-year-old Redwood City father of three at the San Mateo Medical Center, an investigation has revealed.
The Institute for Safe Medication, in presenting its report on the August 2004 incident to the county Board of Supervisors on Tuesday, spread blame throughout a dysfunctional hospital safety system for the medical error that killed Armando Castellanos. The independent report, commissioned by the board, cited multiple miscommunications by an overworked staff as responsible for the death.
On August 12, 2004, Castellanos was injected with 10 times the proper dosage of a chemotherapy drug 500 mg instead of 50 mg. He received a second 50 mg injection before his severe symptoms of toxic overdose were diagnosed a week later and his family was notified.
Stating that they preferred not to split a settlement with any of the numerous lawyers who had contacted them, the Castellanos' family sent the County Counsel's Office a letter asking for $1 million and a written apology earlier this year. The claim has been turned over to the medical center's malpractice insurer.
The state Pharmacy Board has reprimanded and fined the hospital pharmacist who issued the 500 mg dose. Licensing action by the state Nursing Board against the nurse who administered the injection is still pending.
Some of the chemotherapy safety improvements recommended by the outside investigation have already been made at the hospital.
"Handwritten prescriptions haven't been allowed since the accident. They all have to be entered into the computer now," said Dave Hook, spokesman for the San Mateo Medical Center. "We put in a ‘stop the line' policy, where anybody with a question about medication can halt the process."
However, some of the costlier technological safeguards also recommended by the investigators may prove too expensive for the county to continue operating its 2-year-old chemotherapy clinic.
"We're researching whether it might be a cost-benefit advantage to contract out
the chemotherapy to another hospital in the county," said Supervisor Jerry Hill, who chairs the medical center board.
At Tuesday's supervisors meeting, board members were also supposed to consider a whistle-blower ordinance that would require prompt reporting of any possible medical errors at the county hospital. However, decision on the ordinance was postponed until the board's May 17 meeting.
"We want to make the language as specific as possible on what needs to be reported to the supervisors and the hospital administration and the timing,"Hill said.