If you can read this, either the style sheet didn't load or you have an older browser that doesn't support style sheets. Try clearing your browser cache and refreshing the page.

(Some Guy)   Trainee injects drug in patient's spine instead of administering it intravenously. Um... rookie mistake?   (thestandard.com.hk) divider line 65
    More: Scary  
•       •       •

12886 clicks; posted to Main » on 11 May 2010 at 8:46 AM (4 years ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



65 Comments   (+0 »)
   

Archived thread

First | « | 1 | 2 | » | Last | Show all
 
2010-05-11 04:59:41 AM
I doubt anyone would do so on purpose, so the answer is yes.
 
2010-05-11 05:02:49 AM
Link requires registration to read the entire article.

www.scmp.com
 
2010-05-11 05:10:58 AM
I would pay somebody big bucks to inject an opiate into my spine.

Mmmmmmm.
 
2010-05-11 08:49:44 AM
It took me about ten seconds to find this in the package insert instructions for vincristine:

Vincristine may be administered by intravenous push or injected into the tubing of a running intravenous infusion, over a 1-minute period. Do not administer vincristine intrathecally, because death of the patient will occur.

Yeah, that's a bit more than a rookie mistake. That's a "please go work in a dress shop, because your attention to detail may not be quite up to doctor level" mistake.
 
2010-05-11 08:50:14 AM
That sounds like a painful way to go.
 
2010-05-11 08:50:29 AM
Intravenous vs Intrathecal?

kinda hard to mess up... but sure, accident I suppose.
Not like the person that injected glitter into a deputy sheriff.
 
2010-05-11 08:51:56 AM
dahmers love zombie: Yeah, that's a bit more than a rookie mistake. That's a "please go work in a dress shop, because your attention to detail may not be quite up to doctor level" mistake.

Do you realize the level of scrutiny that most garments go through before being shipped off to the States or Europe? She'd be lucky to get a job in an H&M sweat shop.
 
2010-05-11 08:53:49 AM
You know what also causes death?

Cancer.
 
2010-05-11 08:53:56 AM
22 days AFTER the shots?

Yeah, I am so believing it was ALL that "rookie's" fault.

If this were here in the USA, I'd know it was some "distraught family" just looking to cash in on their loved one's demise. But Honk Kong? meh... maybe they are looking towards the west even more than we'd thought.
 
2010-05-11 08:54:32 AM
Bathia_Mapes: Link requires registration to read the entire article.

Patient died after wrong injection

Colleen Lee

Tuesday, May 11, 2010

A drug wrongly injected into leukemia patient Lui Hau-lam's spine bore a label stating that it could only be administered intravenously, the Coroner's Court was told yesterday.

The 21-year-old patient died 22 days after oncology trainee Linda Leung injected the anti- cancer drug vincristine into her spine instead of her veins on June 15, 2007, at Prince of Wales Hospital.

Lei Ieng-kit, the doctor in charge of Lui's treatment, told the inquest that the label on the vincristine syringe normally states the drug is for intravenous use only, which means it can only be injected into patients' veins.

Lei testified that if vincristine is injected into a patient's spine, it can cause serious damage to the central nervous system, and even death.

At about 12,30pm on June 15, Lei prescribed the patient six oral drugs, as well as intrathecal cytarabine, which is injected into the spine, and intravenous vincristine.

He asked Lui to return later in the afternoon to have the injections when the drugs were ready.

Leung was on duty in the treatment room that afternoon and was responsible for giving injections.

Lei said Leung had not consulted him before injecting Lui, as this was not required as long as doctors are sure about the injection route.

Lei also admitted that before Lui's incident, there was no rule that doctors must inject intravenous and intrathecal drugs at different times.

But the hospital introduced the measure after the tragedy, the inquest was told.

Lui's mother, Ho Kwok-yee, testified her daughter complained of a headache and leg weakness when they got off a minibus en route to their Ma On Shan home late that afternoon.

Lui vomited that night and could not sleep well, the mother said. The next morning, she saw her daughter lying on the sofa with a stiff neck.

Ho said her daughter, who was feverish, also complained of feeling pain all over her body, so she immediately called an ambulance.

Chan Tung-ching, another doctor who had treated Lui, said she was on leave at the time of the June 15 injection and only got to know about the patient's condition three days later. Following a discussion with Leung, Chan suspected vincristine might have been injected into the spine, the court heard.

Chan said she and Leung immediately reported their suspicions to Tony Mok Shu-kam, an academic at the Chinese University's department of clinical oncology, as Lei could not be reached at that time.

The inquest continues today.

/That's a lot of Leungs, Luis and Leis. And the author is a Lee
//Am a 'Leung'
///SCMP has a wine reviewer called Simon Tam.
 
2010-05-11 09:00:29 AM
KatjaMouse
That sounds like a painful way to go.



Yeah, very to put it mildly.
I'm not familiar with Vincristine in particular, but generally speaking chemo drugs kill off cells indiscriminately, and in a concentrated area where it's almost totally nerves......

Yeah, probably a very very painful way to go.
 
2010-05-11 09:00:37 AM
Socialized medicine?


scary
 
2010-05-11 09:01:51 AM
Oh my

/vewry, vewry wong
 
2010-05-11 09:03:08 AM
jayday: KatjaMouse
That sounds like a painful way to go.


Yeah, very to put it mildly.
I'm not familiar with Vincristine in particular, but generally speaking chemo drugs kill off cells indiscriminately, and in a concentrated area where it's almost totally nerves......

Yeah, probably a very very painful way to go.


Which is why I couldn't bring myself to say anything else other than that. I mean, how can you deal w/ that kind of systematic shutdown of your body and being aware of it all for the most part?
 
2010-05-11 09:04:14 AM
happens more often than you think.
 
2010-05-11 09:07:44 AM
huckleberg: happens more often than you think.

(citation needed)
 
2010-05-11 09:08:48 AM
KatjaMouse: I mean, how can you deal w/ that kind of systematic shutdown of your body and being aware of it all for the most part?

If it were me? I'd request my cranium be ventilated ASAP.

/Gotta put that in my will or something.
 
2010-05-11 09:09:53 AM
I blame Bush
 
2010-05-11 09:09:56 AM
I doubt anyone would do so on purpose, so the answer is yes NO.

I had a one-nighter with a girl who was thinking about going to nursing school, and I know not to do this.
 
2010-05-11 09:16:16 AM
Phil Herup: Socialized medicine?


scary


Socialized medicine has nothing to do with it. I have friends and family who are nurses. Believe me when I say you'd better watch out for your loved ones personally while they are in the hospital. Over worked, tired people make mistakes more often than you'd like to know.
 
2010-05-11 09:19:53 AM
"At about 12,30pm on June 15, Lei prescribed the patient six oral drugs"

Well..Which is it? 12PM or 30PM?

/I know, I know
 
2010-05-11 09:20:55 AM
docmattic: huckleberg: happens more often than you think.

(citation needed)


http://www.jointcommission.org/SentinelEvents/Statistics/

On the statistics page, there is a section for "Medication Errors". 8.1%, of 547 of the sentinel events (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof) were caused by medication error. This includes an error in any of the five rights (right patient, right drug, right dose, right route, right time).

And this is just the ones that are reported to the joint commission.
 
2010-05-11 09:23:42 AM
Before the typo police strike, it should have been 8.1% OR 547 of the sentinel events
 
2010-05-11 09:38:49 AM
KatjaMouse: That sounds like a painful way to go.

jayday:L Yeah, very to put it mildly.
I'm not familiar with Vincristine in particular, but generally speaking chemo drugs kill off cells indiscriminately, and in a concentrated area where it's almost totally nerves......
Yeah, probably a very very painful way to go.

KatjaMouse: Which is why I couldn't bring myself to say anything else other than that. I mean, how can you deal w/ that kind of systematic shutdown of your body and being aware of it all for the most part?



Not to mention the type of neuropathic pain that slowly progressing deterioration of nerves would probably cause almost body-wide. I could only imagine that it would make cancer seem like a picnic.

I just hope to God they at least put her in an induced coma, before things got real bad.
 
2010-05-11 09:41:21 AM
I know a guy who's been fighting cancer for better than ten years. He recently died. Not because of cancer, but because they gave him some oral chemo and he vomited and aspirated it into his lungs and died because his lungs absorbed it much faster than the stomach.
 
2010-05-11 09:42:36 AM
Phil Herup: Socialized medicine?

scary




*points and laughs*
 
2010-05-11 09:43:07 AM
Egads, I hate being used as a practice dummy.

Checked into ER one time dehydrated due to stomach flu. It took three techs and a dozen tries to get the IV in. The went through every injection point on both arms until a somewhat experienced guy ended the madness and worked the needle into the back of my hand.

Thing is, I'm a veteran blood donor. Every time I donate it's a different person, every time they use the same vein (they love how it sticks out from the inside of my right elbow), and every time they never miss. Seeing these epileptic monkeys posing as EMTs fumbling with my arms was as demoralizing as it was pathetic.

/yeah yeah cool story bro
 
2010-05-11 09:47:42 AM
dahmers love zombie:
It took me about ten seconds to find this in the package insert instructions for vincristine:

Vincristine may be administered by intravenous push or injected into the tubing of a running intravenous infusion, over a 1-minute period. Do not administer vincristine intrathecally, because death of the patient will occur.


PICARD FACEPALM

Jesus, it doesn't get much clearer than that.
 
2010-05-11 09:50:25 AM
No Such Agency: Jesus, it doesn't get much clearer than that.

I dunno, how about

INJECT THIS STUFF INTO THE SPINE AND THE PATIENT WILL DIE!!
 
2010-05-11 09:50:45 AM
So I'm curious to the real reason the mistake happened.... was the patient on some other drug that was supposed to be injected into the spine? Seems like an odd location to mistake.

And also... Wouldn't you need a higher gauge needle to get this into the spine?
 
2010-05-11 09:53:19 AM
KatjaMouse: jayday: KatjaMouse
That sounds like a painful way to go.


Yeah, very to put it mildly.
I'm not familiar with Vincristine in particular, but generally speaking chemo drugs kill off cells indiscriminately, and in a concentrated area where it's almost totally nerves......

Yeah, probably a very very painful way to go.

Which is why I couldn't bring myself to say anything else other than that. I mean, how can you deal w/ that kind of systematic shutdown of your body and being aware of it all for the most part?


It sucks
 
2010-05-11 09:53:49 AM
dragonchild: No Such Agency: Jesus, it doesn't get much clearer than that.

I dunno, how about

INJECT THIS STUFF INTO THE SPINE


OK, done. What's the next step?
 
2010-05-11 09:57:18 AM
I remember a U.S. case years ago (pre-digital camera era), when they were photographing a spinal surgery for a teaching hospital.

Someone in the O.R. managed to inject a chemical photograph fixative into the patient's spinal column, instead of whatever they were supposed to inject.

Didn't turn out well.
 
2010-05-11 09:57:40 AM
WelldeadLink: OK, done. What's the next step?

Page the morgue?

/Well played, well played
 
2010-05-11 09:58:27 AM
huntercr: So I'm curious to the real reason the mistake happened.... was the patient on some other drug that was supposed to be injected into the spine? Seems like an odd location to mistake.

And also... Wouldn't you need a higher gauge needle to get this into the spine?


the article said one of her drugs was to be administered intrathecally while a few were oral and intravenous.


Lei prescribed the patient six oral drugs, as well as intrathecal cytarabine, which is injected into the spine, and intravenous vincristine


My husbands intrathecal med was in a pump in his abdomen that ran continuous to his spinal column but yes - not only would the needle be a higher gauge but also longer (but was already there since one of the meds was intrathecal).
 
2010-05-11 10:03:48 AM
huntercr: Seems like an odd location to mistake. And also... Wouldn't you need a higher gauge needle to get this into the spine?

This would be one of those cases where the mistake was made early on paper so the entirely wrong procedure was followed. It's not like some dumbass picked up a needle and jabbed it into someone's back because they couldn't find the elbow.

Sometimes it seems to me like health care "professionals" would rather just pay higher malpractice premiums and pass those costs on than double-check details. There's an awful lot of variability in doctors and nurses. When you find a good one you stick to him/her, because a lot of them make me wonder how the hell the were ever qualified.
 
2010-05-11 10:15:41 AM
dragonchild: This would be one of those cases where the mistake was made early on paper so the entirely wrong procedure was followed. It's not like some dumbass picked up a needle and jabbed it into someone's back because they couldn't find the elbow.

Yes, it is. Or, rather, the paperwork said some drugs were intravenous and one was intrathecal and the dumbass mixed them up (ignoring a the-patient-will-die label too). RTFA.
 
2010-05-11 10:15:58 AM
i8.photobucket.com

/Wanted for questioning
 
2010-05-11 10:17:17 AM
dragonchild: This would be one of those cases where the mistake was made early on paper so the entirely wrong procedure was followed.

One drug was ordered to go in the spine, one drug was ordered to go in the veins. The trainee mixed them up. An easy mistake, but an unacceptable one.

dragonchild: Egads, I hate being used as a practice dummy.

Checked into ER one time dehydrated due to stomach flu. It took three techs and a dozen tries to get the IV in. The went through every injection point on both arms until a somewhat experienced guy ended the madness and worked the needle into the back of my hand.

Thing is, I'm a veteran blood donor. Every time I donate it's a different person, every time they use the same vein (they love how it sticks out from the inside of my right elbow), and every time they never miss. Seeing these epileptic monkeys posing as EMTs fumbling with my arms was as demoralizing as it was pathetic.

/yeah yeah cool story bro


Your veins were collapsed from dehydration. Makes it more difficult.
 
2010-05-11 10:51:32 AM
img80.imageshack.us
 
2010-05-11 10:51:33 AM
That's why they work 60 hours straight!
 
2010-05-11 11:03:19 AM
mynameismark: *points and laughs*



Stay healthy my friend.
 
2010-05-11 11:07:59 AM
bluefelix: Phil Herup: Socialized medicine?


scary

Socialized medicine has nothing to do with it. I have friends and family who are nurses. Believe me when I say you'd better watch out for your loved ones personally while they are in the hospital. Over worked, tired people make mistakes more often than you'd like to know.


Two members of my family are nurses. They each work standard shifts of twelve hours per day. They are frequently asked to work into the next shift. They state that they are continually urged to work faster. And in this article you have a trainee dealing with this pressure and administering the shots. Why wasn't there someone in the room supervising her? You know, someone who could have said "Whoa, perhaps you're not familiar with this medication and the proper way to administer it? Why don't you read the insert first?"
 
2010-05-11 11:18:05 AM
dragonchild: Egads, I hate being used as a practice dummy.

Checked into ER one time dehydrated due to stomach flu. It took three techs and a dozen tries to get the IV in. The went through every injection point on both arms until a somewhat experienced guy ended the madness and worked the needle into the back of my hand.

Thing is, I'm a veteran blood donor. Every time I donate it's a different person, every time they use the same vein (they love how it sticks out from the inside of my right elbow), and every time they never miss. Seeing these epileptic monkeys posing as EMTs fumbling with my arms was as demoralizing as it was pathetic.

/yeah yeah cool story bro


It's unfortunate when you get someone who sucks at starting IVs, but the bottom line is they have to learn it somewhere. Doctors, nurses, EMTs, and the like don't just burst into existence as masters of their craft. Practicing on real patients is the only way to build those skills and most people aren't too good at the beginning.

Also, for what it's worth, sometimes there are reasons to go for veins in certain spots even if they are harder to get. When I used to work in EMS it was standard policy to start IVs at the farthest out site possible except in a critical patient. The reason being if you blow an IV in the hand you can just go further up the arm. If you start at the elbow and blow it, your next option is the neck (assuming you've already gone for the other arm). It also keeps the bigger veins available in case they need a bigger line later. Starting in the hand gives you more chances to get a good line, which is important for an emergency patient. When you're donating blood it doesn't matter because they can just tell you to come back tomorrow.
 
2010-05-11 11:20:44 AM
Vertdang: Intravenous vs Intrathecal?

kinda hard to mess up... but sure, accident I suppose.
Not like the person that injected glitter into a deputy sheriff.


"The Research on Adverse Drug Events and Reports (RADAR) project of Northwestern University conducted a review of the literature published from 1968 to June 2006. Since 1968, 55 cases of inadvertent intrathecal vincristine have been reported worldwide."
Link (new window)

Not exactly a non-event either, which is why we take such extreme steps to prevent this happening in our hospital. And totally irreversible at this time.
 
2010-05-11 11:35:13 AM
Arcturus72: 22 days AFTER the shots?

Yeah, I am so believing it was ALL that "rookie's" fault.

If this were here in the USA, I'd know it was some "distraught family" just looking to cash in on their loved one's demise. But Honk Kong? meh... maybe they are looking towards the west even more than we'd thought.


From the FDA mandated Black Box warning :

"FATAL IF GIVEN INTRATHECALLY. FOR INTRAVENOUS
USE ONLY.
See WARNINGS section for the treatment of patients given
intrathecal VINCASAR PFS."
Link (new window)

Not "possibly harmful" or " might kill patient". Will kill patient.
No one suing after such an incident is suing without just cause. This is a well know problem and any facility administering it should have well defined and FOLLOWED procedures to prevent this kind of thing from happening.
 
2010-05-11 11:38:22 AM
Ah, sorry, ONE patient has survived, when the mistake was discovered immediately and extreme measures were taken.
 
2010-05-11 11:39:47 AM
benlonghair: I know a guy who's been fighting cancer for better than ten years. He recently died. Not because of cancer, but because they gave him some oral chemo and he vomited and aspirated it into his lungs and died because his lungs absorbed it much faster than the stomach.

that's horrible. really awful.
 
2010-05-11 11:43:13 AM
fluffy2097: You know what also causes death?

Cancer.


Yeah, but successful treatments can add years of life - or a decade! - even if the cancer gets you eventually.

That can be a big deal. And if you've been dealing with the cancer for a while, you get used to the idea that death will come "eventually". In the meantime, any treatments that puts off the inevitable feels like a victory. And going suddenly would be hard to take.
 
2010-05-11 11:54:06 AM
Vincristine is one of the agents akin to mustard gas, a blistering agent if I recall correctly. You don't want it in your spine.
 
Displayed 50 of 65 comments

First | « | 1 | 2 | » | Last | Show all



This thread is archived, and closed to new comments.

Continue Farking
Submit a Link »






Report