Hospital Has Been Working To Cut Its Medical MistakesJan 17, 2003 | Rocky Mountain News
The Denver hospital where a pregnant woman died last month from a medication overdose was the site of a similar mistake in March, after which new safety procedures were started to try to prevent more deaths.
Genesis Metcalfe, 24, died Dec. 20 at Presbyterian-St. Luke's Medical Center, where she'd come because of premature labor. Denver coroner Tom Henry said Metcalfe's death was caused by acute magnesium sulfate toxicity.
Magnesium sulfate can slow contractions, said Henry, but Metcalfe had three or four times the dosage usually recommended. Magnesium sulfate can keep smooth muscles from contracting, but at higher levels it can affect the heart and respiration muscles, Henry said.
At the dosage Metcalfe received, "It would be difficult to get the heart beating again, unless you could decrease the magnesium rather abruptly."
Metcalfe's baby boy, delivered through Caesarian section, survived.
In March, a man in his 80s received five times the ordered amount of Versed after revascularization surgery at P/SL. The man went into cardiac arrest and died. The hospital reported the death to the Colorado Department of Public Health and Environment, as required by law.
In the March case, a doctor had asked that a 10-milligram syringe of Versed be prepared in P/SL's post-anesthesia care unit. Nurses prepared the syringe of Versed, a sedative and muscle relaxant.
As the patient arrived in the unit, the doctor ordered 2 milligrams to be given in a direct push intravenously.
The nurse only heard the order to do the direct push, not the order to use 2 milligrams rather than 10, according to the report.
After the death, P/SL implemented a policy that all verbal orders by doctors be repeated back to the doctor to prevent medication errors.
That policy is standard practice, said P/SL spokeswoman Stephanie Lewis. The hospital is respecting the family's request not to talk about the Metcalfe case, Lewis said.
P/SL has the most beds, 680 of any hospital in the metro Denver area, but also has had more than its share of controversy.
Last year, P/SL ranked at the bottom of metro Denver hospitals in treating heart attacks and coronary bypass surgery outcomes, in a survey by HealthGrades.
But P/SL surgeons said the hospital gets more than its share of severe cases, and that another survey that weighed case severity gave P/SL above-average marks.
New research has confirmed the long-held suspicion that accidental deaths and bad outcomes increase when nurses are asked to take care of more patients during a shift.
Last year, when many metro Denver hospitals were closing beds because of the nursing shortage, P/SL officials said they were able to improve their nurse-to-patient ratios, crediting a nurse-education partnership with Regis University.
Ironically, there were more active nursing licenses in 2002 than in any year in recent memory, according to the Colorado Board of Nursing. In 2002, there were 51,282 active registered-nurse licenses, compared with 46,676 the year before. The number of active certified-nursing-aide licenses increased 25 percent from the previous year.
Last year, 91 nursing licenses were revoked or relinquished by the state nursing board. That's the same as the previous year, and a lower number than in 1998, 1999 or 2000.