Coral Springs mother died from massive overdose given by Broward General nurse

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Ducknet Posted: 01-24-2007 3:29 PM

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I ran across this in a medical blog, scary and it could have been anywere, sad, and everybody loses here.

Coral Springs mother died from massive overdose given by Broward General nurse

By Bob LaMendola
South Florida Sun-Sentinel

January 24, 2007

The Coral Springs mother went to the emergency room feeling sick after running out of medicine. But instead of just getting a refill, she died when a nurse gave her a massive overdose of a seizure drug, according to hospital officials and state records.

The nurse at Broward General Medical Center injected Michelene Plass, 44, with 10 times the dose the doctor ordered, officials said. To get that much, nurse Dionne Cooper had to round up 32 vials of the drug. Plass died in minutes.

Plass' death in April is getting fresh scrutiny, as an outgrowth of a lawsuit filed by her ER doctor, Paul Rohart, who contends he was unfairly dismissed. The nurse also was fired. After Rohart contacted them last week, Broward County prosecutors asked Fort Lauderdale police to begin a criminal review of the case and the nation's hospital accrediting group agreed to examine Broward General's response to the death.

Rohart and Plass' mother said that they were stunned that Cooper would give such a high dosage without double-checking the script and that the hospital's safety system did not catch the error.

"She came to the hospital for help and this is the way she came out," said her mother, Peggy Plass, of Lincoln, Ala. "How could this happen? How could they make a mistake this big? It's beyond belief."

The chief executive of the North Broward Hospital District, a tax-assisted body that owns Broward General, said the nurse and hospital staff were crushed by the fatal error and adopted new practices to prevent similar mistakes.

"All of us are troubled when we have a bad outcome, especially when it's caused by our mistake," CEO Alan Levine said. "It's a tragedy. All we can do is try to learn from it."

The state Department of Health filed action in October to revoke Cooper's nursing license or discipline her for "gross negligence." The case is pending.

Cooper, 37, a nurse for nine years, could not be reached for comment with calls and visits to her Fort Lauderdale home.

Plass' death is one of an estimated 400,000 medication errors that harm hospital patients every year, according to the Institute of Medicine.

Plass was a stay-at-home mother of three children ages 17 to 21, family members said. She jogged or walked 10 miles a day and was in great shape.

"She was a very sweet woman and completely devoted to her children," said her sister, Margaret Gormley.

Plass was taking the anti-anxiety drug Klonopin, but had no health coverage and did not get more when her pills ran out, an autopsy report and state records show. Stopping Klonopin can cause seizures, the health department said.

On April 23, Plass had a seizure and was rushed to the hospital, her mother said. She was discharged with a refill of her medicine, but before she could leave, she had another seizure in a bathroom, records show.

Rohart, an ER specialist for eight years and a doctor since 1989, said he ran tests and prescribed 800 milligrams of the anti-seizure drug Dilantin. "She and I were laughing when I left for the day," Rohart said.

But Cooper instead administered 8000 mg (eight grams), quickly stopping Plass' heart, hospital officials said. The fatal dosage is two to five grams.

"Her husband called me to say they were releasing her from the hospital," Peggy Plass said. "Then 10 minutes later he called to say she was dead."

The correct dose required 3.2 vials of the drug. Cooper gave Plass 32 vials, hospital administrator Joe Scott said. To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. "That would be a big red flag," Scott said.

All the Dilantin didn't fit in one intravenous bag, so Cooper hooked up two, one in each arm, Scott said. "That would be another big red flag," he said.

Cooper never double-checked or questioned the amount, Scott said. Nor did she explain her error to hospital officials, he said.

The death exposed gaps in safety procedures, Scott said, mainly that the drug-dispensing system did not detect such a huge dosage being prepared for one patient.

The machines have been reset to flag large withdrawals and to stock only small amounts of Dilantin and other high-risk drugs, forcing nurses to go to the hospital pharmacy in person, he said. After the death, the hospital retrained nurses and tested them on calculating dosages.

"I have a sense of comfort that they have taken all the steps necessary," Levine said.

District officials agreed on Aug. 11 to pay Plass' husband, Randall Woodin, $200,000 to avoid a lawsuit.

Rohart, meanwhile, said he was warned by an ER director against asking questions about the death but did so anyway. The day of the settlement, Rohart was ordered to a later meeting where he was fired as of Nov. 13, he said in his November lawsuit filed in Broward courts. The news came from his employer, Phoenix Physicians, which manages ERs for the district.

Rohart said he was fired on the spot Sept. 15, after his bosses learned he called the husband. He said Woodin told him the settlement deal included firing Rohart and Cooper.

"I was shocked. What did I do wrong?" he said. Rohart, now practicing near Tampa, sued Phoenix for retaliation, asking to be rehired with $105,000 in back pay.

Phoenix, in court papers, said Rohart's firing was unrelated to Plass' death. The company declined to comment. Woodin could not be contacted with calls to his phone. Levine said the hospital "absolutely did not" retaliate against Rohart or demand his dismissal.

"Michelene didn't deserve this," said Plass' mother. "It's all about money now for them. It's pretty sad when someone's life can be bought for $200,000."

Bob LaMendola can be reached at blamendola@sun-sentinel.com or 954-356-4526.

http://www.sun-sentinel.com/features/health/sfl-rxod24jan24,0,4783352,print.story?coll=sfla-travel-print

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DrMurdoch replied on 01-24-2007 5:32 PM

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The chief executive of the North Broward Hospital District, a tax-assisted body that owns Broward General, said the nurse and hospital staff were crushed by the fatal medication error and adopted new practices to prevent similar mistakes.

Gosh a drug error killing a patient ? *SHOCK*. Similar mistakes have been made 100s/1000s of times - they did the policy review to look good.

Plass was taking the anti-anxiety drug Klonopin, but had no health coverage and did not get more when her pills ran out, an autopsy report and state records show. Stopping Klonopin can cause seizures, the health department said.

Another killed by no insurance ?

The correct dose required 3.2 vials of the drug. Cooper gave Plass 32 vials, hospital administrator Joe Scott said. To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. "That would be a big red flag," Scott said.
All the Dilantin didn't fit in one intravenous bag, so Cooper hooked up two, one in each arm, Scott said. "That would be another big red flag," he said.

Uh oh.

I think the real question is... did the 800mg of dilatin (likely written on paper) look like 8000 and thus it was a problem with the handwriting ? (probably not). Sounds like the nurse misinterpreted 800 as 8000. I guess if the nurse knew that 8000mg was 2.5x the lethal limit she might not have given it. It certainly doesn't take much of a computer program to display typical doses of a drug to a nurse that is about to administer a drug.

How exactly do you put 32 vials in an IV bag anyway ?

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Robert Gleeman replied on 01-24-2007 6:33 PM

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That's a horrible story. On the opposite end of the spectrum, I got a call on the phone an hour after taking a routine blood test. It seems my blood glucose level was 50, and the doctor called to make sure I was OK.

You can't fake good medical care. Even a child can tell the difference.

I'll bet those drug dispensing machines are mainly to prevent the nurses from stealing the drugs, not to help them use them more safely.

An order-taker at Burger King has a better computer system than most nurses do, and that's exactly what I am here to help change. If I have any "agenda", it is to help doctors catch up to waiters and auto mechanics in their beneficial use of computers.

Never once have I ordered chicken but received fish.

Never once has anyone tried to install a Ford part in my Chevy.

But once, I did receive the wrong drug from the pharmacy.

Robert Gleeman, Medical Journalist for EMR Update.com
Email: robert@emrupdate.com
Tel: 1-650-968-6359
Skype and ooVoo user name: robertgleeman
EMR progress is a matter of fact.
EMR Update supports your right to know.

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dagmar replied on 01-25-2007 7:28 PM

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Robert Gleeman:
Never once have I ordered chicken but received fish.
Never once has anyone tried to install a Ford part in my Chevy.
But once, I did receive the wrong drug from the pharmacy.

The complexity of running a fully-stocked, modern pharmacy can't be compared with ordering a sandwich from Burger King or bringing your car in for a tune-up. I'm sure you know that, but your examples are not legitimate for comparison purposes.

But your point (I think) is taken: the opportunity for human error in the dispensing of medicine is still at unacceptably high levels.

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sweaner replied on 01-26-2007 3:33 PM

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There is one thing an EMR would not have helped in this case.

Dilantin is NOT the treatment for withdrawal seizures!

Scott

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Brendon replied on 04-16-2007 5:10 PM

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As a follow up to this story. This customer is a prime site user for a leading EMR and my Mother was just there. They have all of the best in technology, so obviously technology is not the answer to patient care.

Brendon

Brendon Holt President http://www.holtsystems.com eMedRec Medical Records Made Friendly "If it wasn't for that last minute I would never get anything done."

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DrMurdoch replied on 04-18-2007 7:03 PM

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sweaner:
There is one thing an EMR would not have helped in this case.
Dilantin is NOT the treatment for withdrawal seizures!
Scott

:) a classic post !

Brendon:
As a follow up to this story. This customer is a prime site user for a leading EMR and my Mother was just there. They have all of the best in technology, so obviously technology is not OFTEN the answer to BETTER patient care.
Brendon

Computers don't make nurses smarter.

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DrMurdoch replied on 04-18-2007 7:05 PM

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sweaner:
There is one thing an EMR would not have helped in this case.
Dilantin is NOT the treatment for withdrawal seizures!
Scott

:) a classic post !

Brendon:
As a follow up to this story. This customer is a prime site user for a leading EMR and my Mother was just there. They have all of the best in technology, so obviously technology is not OFTEN the answer to BETTER patient care.
Brendon

Computers don't make nurses smarter.

email:

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Coral Springs mother died from massive overdose given by Broward General nurse

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