Anatomy of a Tragic Hospital Staff Error

Ran Reznick
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Ran Reznick

What caused Dr. Yosef Shental, head of Haemek Hospital's urology department, to order Optalgin for a patient last December, despite the fact that the man's allergic sensitivity to the medicine was cited repeatedly in his medical file? Why did one nurse in the department relay the same order for the administration of the drug? And why did a second nurse give the patient Optalgin, despite the sticker on his bed that cited his allergy to the drug? Did taking the drug cause the death of the patient, T.G., 77?

These are some of the questions investigated by a special Health Ministry committee, which submitted its findings to ministry officials a few days ago.

"It is completely clear," the committee concluded, that the patient developed an allergic response to the Optalgin he received at the Haemek ward and that this wrongly-administered drug "led, in the end, to his death."

The order to administer the drug, concluded the committee, was given by Dr. Shental and was carried out even though the hospital staff knew that the patient was sensitive to Optalgin and even though his allergy was cited by seven red stickers pasted in his medical file, and on his hospital bed.

"It is absolutely clear," wrote the committee, "that despite all the warning signs and red lights, despite the many places in which it was clearly noted that the patient was sensitive to Optalgin, a sequence of errors occurred. Mechanisms designed to ensure correct procedure and to prevent mistakes of this kind collapsed."

That the head of a hospital department would carelessly give a mistaken medication order, "without checking the patient's medical file," is "very hard to explain," the committee's report stated. "Then, furthermore," the report wrote, "a nurse in the department copied the order without relating to the warning stickers, either because of carelessness or blind faith in the department head and a lack of desire to verify his instructions."

Responding to the committee's findings, Health Ministry ombudsman Prof. Shimon Glick last week informed Haemek Hospital director Dr. Eran Halperin that disciplinary measures are to be taken against Dr. Shental and the two nurses in the urology department, Neta Zavavi and Vera Poliakov, who were involved in administering the medication to the patient. The ministry ombudsman is empowered to impose punishments including warnings, censures or even the revoking of professional licenses.

Attorney Eran Kazman, who represents both the doctor and the two nurses, says that the case involves an "unavoidable" failure. What happened, the lawyer claims, was a human error that does not warrant the imposition of disciplinary measures against the physician or the nurses. "The investigative committee did not recommend that such measures be carried out," he says.

All members of the hospital staff interviewed in the inquiry spoke "honestly, and the testimony they provided was reliable," stated the committee. "Dr. Shental and the nurse, Vera Poliakov, took full responsibility for what happened. They have drawn the appropriate conclusions. They made no attempt to pass responsibility on to one another, or to other members of the staff."

The committee concluded that "Haemek Hospital's administration must use this incident as a chance to reclarify work procedures followed by doctors and nurses in all hospital departments with respect to understanding a patient's needs and studying each patient's medical file." Such a hospital-wide review should "emphasize the responsibility borne by each staff member to identify mistakes of this sort as soon as possible, and to prevent them from occurring."

T.G. suffered from bladder cancer and he underwent a number of operations and treatments at Haemek's urology department in the past decade. Since he was often hospitalized, the department staff was acquainted with details of his case, including his allergy to a number of drugs - Optalgin, Aspirin and Codeine.

He was hospitalized in December 2001 due to a urinary disorder and concerns about the possible spread of his cancer. Dr. Shental performed an hours-long surgical procedure and then ordered that the patient receive dosages of Optalgin to relieve the pain. The doctor relayed this order despite the fact that G.'s allergy was cited repeatedly in his medical file. Dr. Shental told the committee that he had issued a "routine order for a pain-killing drug."

According to the department's medical records, the drug was given to the patient by nurse Vera Poliakov. The nurse told the committee that while administering the drug, she "spoke with the patient about other matters and didn't realize that she had forgotten to ask him about allergies, even though she recalled that one of the patients in the department to whom medicine had been given had a sensitivity to a certain drug."

Due to "carelessness," Poliakov admitted, she "did not pay attention to the sticker on the bed" that cited the patient's sensitivity to the drug.

Two days after the patient received the Optalgin, a skin irritation resembling a second degree burn appeared all over his body. His allergic response was diagnosed, and he was originally treated with antibiotics and skin cream in the urology department. His condition worsened after a few days and he was transferred to the hospital's intensive care unit, where he passed away.