A replacement nurse working during the recent strike at Abbott Northwestern Hospital severely injured an asthmatic patient by administering adrenaline in a way that dangerously contradicted a doctor’s order.
The Sept. 17 medication error caused a rapid and then irregular heartbeat in the woman, who lost consciousness and was placed in intensive care for three days, according to interviews and results of a federal Medicare investigation obtained by the Star Tribune.
One month later, the patient, Joyce Togba, is progressing with physical therapy to regain the strength and feeling she lost, and Medicare has accepted a plan by Abbott to prevent future errors.
But the incident raises fresh questions about whether providers such as Allina Health are able to maintain patient care when thousands of nurses walk off the job.
“That just never should have happened. I suspect it was due to people who were not used to working with one another” during the strike, said Gary Manka, Togba’s attorney. He added that Togba, 39, has limited sensation in one leg that makes it difficult to walk or drive.
Allina’s chief medical officer acknowledged Friday that the medication error resulted from a breakdown in emergency communications, but said it was an exception rather than a reflection of broader care problems caused by the strike.
“We have a responsibility to the community, so there was a lot of preparation that went into making sure we had the right nurse with the right training that we could get to the right parts of our (hospitals),” said Dr. Timothy Sielaff.
When more than 4,000 nurses went on strike for one week in June, and then one month this fall, Allina recruited more than 1,000 replacement nurses from across the country to keep its Twin Cities hospitals running. The nurses’ union, the Minnesota Nurses Association, created a website where patients could report care problems, and received 65 complaints that it forwarded to health care regulatory and licensure agencies.
To date, none of those have produced regulatory sanctions against the five hospitals that were under strike: Abbott, United in St. Paul, Mercy in Coon Rapids, Unity in Fridley, and the Phillips Eye Institute in Minneapolis.
The union’s concern, however, is consistent with one of the only research studies to assess the quality of care during strikes, a 2010 paper by the National Bureau of Economic Research (NBER). It examined hospital strikes in New York from 1984 to 2004 and found a 19.4 percent increase in in-hospital mortality during those events.
The Star Tribune conducted an elementary review of preliminary state death certificate data and found that the number of patients who died in the Allina hospitals increased from 115 in August to 135 in the 30-day period between Sept. 5 and Oct. 4. (The strike didn’t start until Sept. 5.)
However, mortality also increased at hospitals statewide from August to September, the data show, so the specific role of the strike is unclear.
The Star Tribune analysis was limited, lacking the statistical tools the NBER used to weigh the sickness, or acuity, of patients in the New York hospitals during normal operations and when they were under strike.
Sielaff said Allina routinely analyzes its hospital mortality and morbidity rates, and will do so for the period of the strike when final data is available.
After Allina officials reported the medication incident, regulatory authorities declared a state of “immediate jeopardy” at the hospital on Oct. 3. A state inspector interviewed the caregivers involved that same day to determine if any federal Medicare standards of care were violated.
Order is misunderstood
As Togba wheezed and struggled for breath in Abbott’s emergency department Sept. 17, Medicare records show that a doctor, a pharmacist and a nurse were in her room providing treatment along with three or four others.
Albuterol mist to open her airways hadn’t resolved the problem, so a doctor ordered a 0.3 milligram dose of epinephrine, also known as adrenaline, records show.
The doctor asked for the dose to be administered by direct injection into a muscle, or IM. The pharmacist heard that as well, records show, and told the nurse to give the medication that way. The nurse countered that he didn’t hear the doctor order a specific route, and was told “yes” when he asked the doctor if it should be given intravenously, or by IV.
Such an order would have been unusual, considering that IV epinephrine is reserved for patients in cardiac arrest who need resuscitation. A dose intended for injection also is considerably stronger than a dose placed directly into the bloodstream, Manka said.
Togba immediately “felt like her entire body was on fire from the inside.” Manka said. Before losing consciousness, Togba heard the doctor exclaim “what the (expletive) did you just do,” he added.
The first public notice of the incident was a legal statement published in the Star Tribune on Oct. 13 — which happened to be the day nurses were voting on a contract to end their historically long strike.
The full report on the incident wasn’t available until Thursday, after Medicare officials accepted Abbott’s correction plan.
The plan calls for the addition of a nurse observer when needed in critical cases, the retraining of ER staff on repeating back verbal orders to eliminate confusion, and the use of preloaded injectable epinephrine pens that could never be used intravenously.
Medication errors are not unheard of
Sielaff said he doesn’t view the error as a result of the strike, because it was more due to a breakdown in established communication procedures.
“We try not to look at this as the fault of the individual,” he said. “We try to look at this as a team and a system.”
Other records also suggest that the error could have occurred with regular nurse staffing. Mistakes in the administration of epinephrine are so common, due to confusion over dosing amounts and terminology, that the Pennsylvania Patient Safety Authority issued a special advisory about it in 2006.
And state records show that Minnesota routinely reports about five to six medication errors each year in hospitals statewide that result in patient deaths or severe disabilities.
Sielaff said other indicators of patient care didn’t worsen during the strike, such as the numbers of patient falls, bed sores or urinary tract infections.
Increased inspections by the Minnesota Department of Health didn’t detect patient care threats either.
“We welcomed (the inspectors) coming in,” Sielaff said, “because we consider ourselves to be a community asset and we need the community to be confident in all circumstances of the services we’re providing.”
Togba remained in hospital care for several days before starting physical and occupational therapy for her leg weakness. A customer service worker at Abbott, Togba hasn’t been able to return to the hospital to work.
Her breathing problems actually started on the job, Manka said, when she suffered a reaction due to a whiff of a visitor’s cologne. The St. Paul mother of two was first told that her Allina health insurance wouldn’t cover her physical therapy sessions, but Manka said it appears they will be covered.
The attorney is fighting with Allina over whether the incident was a workplace injury that would quality for workers’ compensation benefits.
“We were kind of surprised,” Manka said, “when Allina came back and turned it down.