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Wednesday, April 11, 2007

I’m sure they have some record: A laboratory medical error

The last time she saw her father - a soft-spoken man who "always had a joke for everyone" - was when she visited her parents' home in Florida for Christmas. "He was great," Jeanne Zeller said. "He even carried my luggage for me."

Around a week later, though, Thomas Zeller started to have shoulder pain. After enduring it for a week, the 69-year old man checked into the hospital, on Jan. 8, 2006. His initial vital signs were normal and his chief complaints were left shoulder pain and right hand swelling. X-rays of Zeller's left shoulder showed a slight dislocation of bone. On his first day in the hospital, he was given a Foley catheter to help with urine retention.

Thomas' temperature spiked to 102 degrees during the late evening of Jan. 11, and a blood culture was taken the next day. Meanwhile a cardiac catheterization on Jan. 11 had suggested dysfunction of the heart muscle (cardiomyopathy). Though the condition was serious, it didn't warrant his staying in the hospital any longer, and he was discharged to a nursing home on Jan. 14.

Thomas’ fever continued to spike during the next week, while he was having rehabilitative physical therapy in the nursing home. At the end of that week, he was transferred back to the hospital, on Jan. 20. There, the blood and urine cultures revealed Pseudomonas aeruginosa, a "superbug" resistant to most antibiotics. From there, his condition deteriorated, as the infection spread to his heart valves. On Feb. 15, Zeller's wife signed the "do not resuscitate" order, and he died soon afterward.

The superbug had spread, unknown and untreated, for a week, because the Jan. 12 blood culture result was delayed or missing until after he left the hospital. "By not having important lab results in the chart in a timely manner," Jeanne Zeller wrote to the Florida Agency for Health Care Administration, the hospital "sentenced my father to death."

The most likely explanation: "Persistent Pseudomonas aeruginosa bacteremia blood poisoning probably started off as a urinary tract infection," Dr. Murali Puthisigamani wrote after examining Thomas on Jan. 30.

The hospital had made at least three errors. First, unsanitary conditions were surprisingly prevalent. Three of nine patients sampled by AHCA "were not provided catheter care and/or personal hygiene care," according to AHCA’s report. Second, the initial lab result was delayed. Third, when the critical result was determined, staff told no one. Apparently the hospital had no effective system in place to immediately sound an alarm to doctors when laboratory staff learn of such critical lab results (also called "panic values").

The AHCA inspector had asked the infection control nurse why Thomas Zeller's Jan. 12 blood culture never made it to his chart. Her response: "If a patient left before the final results were in, they may be - I don't know how medical records does their filing. I'm sure they have some record."

Advice: Before you let your father into a hospital, ensure that the hospital participates in the Five Million Lives campaign of the Institute for Healthcare Improvement.

Read a story on misplaced lab results, or read Elena Lesley’s source story, dated April 1, 2007.

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