Did Nine Patients Have to Die?

Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.

What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?

This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.

Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes?

The facts of the Alabama deaths have started to emerge.  Apparently, a water faucet in the pharmacy was contaminated. Protocols and processes are violated every day in all spheres of professional life; and we usually get away with them. The absence of serious consequences breeds complacency, which is shattered by an occasional tragedy. Isn’t it after a horrible traffic accident that a local government decides to erect street lights that were requested by local residents for years? I read earlier today that the Federal Aviation Administration is requiring extensive inspections of a few hundred airplanes when small cracks were discovered in a few of them. This followed a near disaster when a 5 foot hole burst open in the roof of an airplane during flight. The plane landed and all survived. Of course, a very different outcome was possible.

A few weeks back, an airline pilot was puzzled and perturbed when he couldn’t make contact with an air traffic controller at Ronald Reagan Washington International Airport. This wasn’t a mechanical failure but was a matter of zzzz’s. The controller simply nodded off. I suppose it’s preferable for the controller to take a catnap than for the pilot, but there is a process defect in the tower. Afterwards, the Secretary of Transportation announced a new policy that middle school kids could have devised. Air traffic controllers shouldn’t be manning the fort solo. Wow! Real genius advice here from our government. Are these the same brainiacs that make me take off my sneakers before I board an airplane?  (No, these Mensa folks are Department of Homeland Security experts.)

In past years, several people have contracted hepatitis C after undergoing medicine’s most elegant medical procedure – a colonoscopy. These events were not Acts of God but were Acts of Man. They occurred when established procedures were breached for various reasons, none of which are defensible.

While we often cut corners with impunity, on occasion a small and seemingly innocuous deviation can result in unforgiving consequences. The concept of Universal Precautions means what it says. It means do what you are supposed to do every time without exception. Here’s what a list of Partial Precautions might include:

  • Wear seat belts on long car trips only.
  • Physicians should wash their hands only before seeing ICU patients.
  • Do not leave infants alone in the bath on odd numbered days.
  • Give your children two-thirds of recommended vaccinations.
  • Never drive under the influence of alcohol during daylight.

So, the water faucet was dirty. My kitchen faucet isn’t sterile either. However, while I’m no TPN expert, should tap water be used to clean a container that would be used for preparing TPN, which must be 100% germ free?  Similar mistakes are made daily throughout society without causing harm. Lighting a match won’t lead to havoc and destruction. But, when the same match lights a fuse, then the world can go dark.

Any corner cutters out there who want to come clean?

Michael Kirsch, MD, is a private practice gastroenterologist in the Cleveland, OH, area. He shares his thoughts about issues in medicine and medical practice at MD Whistleblower.

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2 replies »

  1. I am not certain what the exact point of your post is regarding Medicare and never events. I was at first concerned when this list came out, too – but think of it as an act of desperation after decades of hospitals and physicians failing to address preventable harm on their own. We got what we deserved.

  2. Great article!

    It shows how terrible things can happen if protocol is not followed in health care. Protocol is there for a reason, and this is emblematic of those reasons.

    When bad things happen in organizations, it is usually a systemic failure, meaning that the protocol does not have sufficient checks at certain points in the process. Once the hospital implements these checkpoints and sticks to them, the likelihood of another fatal mishap will decrease dramatically.

    Mark Cohen