Mayo hospital admission of death the ‘right thing’

Posted June 14, 2010, at 10:51 p.m.
Last modified Jan. 29, 2011, at 11:38 a.m.

DOVER-FOXCROFT, Maine — A state official commended Mayo Regional Hospital officials Monday for taking the unusual step of publicly releasing the details involving the death of a patient who mistakenly received a massive drug overdose on June 4 while under the hospital’s care.

“I admire a hospital willing to do that,” Catherine Cobb, director of the Division of Licensing and Regulation Services of the Department of Health and Human Services, said Monday.

Asked if her department hears about every incident like that which occurred at Mayo, Cobb said, “I can say with certainty that we don’t.” Hospitals don’t typically publicize such deaths, known in the medical community as a “sentinel event,” she said.

While Cobb spoke about the hospital’s openness in dealing with the death and its investigation into the circumstances, she would not confirm that her department also is investigating the incident. In Maine, a reported sentinel event — an unanticipated occurrence in a hospital or health care setting involving death or injury to a patient that is not caused by the patient’s illness — must be kept confidential by the department, although a hospital can release the details, she said.

The sentinel event at the Dover-Foxcroft hospital involved the death of an Atkinson man. While the hospital declined to name the victim, the Bangor Daily News learned that Timothy Harvey, 51, went to the emergency room on June 4 with symptoms of anaphylaxis that included facial swelling and some thickening of the tongue. He had eaten seafood about an hour earlier but had no prior known seafood allergy, according to hospital officials.

Emergency room employees gave Harvey 0.3 milligrams of epinephrine, an appropriate amount, and he showed signs of improvement, according to Mayo Hospitalist Dr. Tom Murray. While Harvey was held for observation, he began to show some of his earlier symptoms, so a second dose of epinephrine, also known as adrenaline, was given to him, Murray said Friday. When the patient began to experience chest pain and shortness of breath later that night, the medical provider reviewed the patient’s chart and realized the patient had mistakenly been given 10 times the normal dose of epinephrine, Murray said. The overdose ultimately caused the patient to collapse and die, despite vigorous efforts to revive him, he said.

Cobb, whose department licenses hospitals, provides federal certifications, and investigates complaints and sentinel incidents when reported, said DHHS typically probes more than 200 complaints against hospitals each year. Violations are found in about 18 percent of those investigations, she said.

According to DHHS’ website, there were 43 reported sentinel events in the state in 2008, the last reporting period available. Of those, 31 were unanticipated deaths from a variety of causes, three wrong site surgeries, seven major loss-of-function cases, a patient rape and a patient suicide.

When a complaint is filed, Cobb said her department interviews hospital officials, the patient’s family and staff. In the event of a sentinel event, the department does a thorough medical records assessment and determines what the hospital did right and what it did wrong, she said. The hospital then is given a laundry list of things that need to be addressed.

It was unclear Monday evening whether details or locations of sentinel events confirmed by DHHS investigations are publicly available.

After waiting for the preliminary findings of an autopsy conducted on Harvey by the state medical examiner’s office and Harvey’s funeral on Wednesday, hospital officials went to the press.

“It was the right thing to do,” Dr. David McDermott, Mayo’s director of emergency services, said Monday of the public announcement. “It’s only by acknowledging that we have a problem that we can truly work not only with ourselves but perhaps with other hospitals.”

There is a national trend toward open disclosure and open dialogue around medication errors, McDermott noted.

Cobb recalled a national speaker on patient safety being asked if there were two hospitals in a community and one reported it had 200 sentinel events and the other hospital reported it had no sentinel events, which one would he go to. The speaker said he would go to the one that acknowledged having had 200 sentinel events be-cause the hospital with no sentinel events just wasn’t looking, she recalled him saying.

While some comments on the Bangor Daily News website were critical of the hospital’s care in light of the announcement, Christy Goodwin of Charleston said the hospital saved the life of her infant son, Corey, last July. She said her son, who was born not breathing, was revived and taken by special ambulance to a Portland hospital. Today, her son is a healthy 11-month-old.

“There are experiences that people have at this hospital that are very positive and very uplifting,” Goodwin said. The fact her son survived shows the hospital does have very qualified people, she said.

While Mayo officials are encouraged by the community support, their thoughts are with the Harvey family.

“No words can express the sense of loss that we know they have and our concern is for them and for their well-being,” McDermott said.

He said the hospital’s thoughts also are with the staff members involved the night Harvey died. “We are reaching out to them and supporting them. This is a difficult time for everybody involved.”

While the grieving continues, McDermott said the hospital continues trying to find out what happened and how changes can be made to avoid another such occurrence. Like Murray, McDermott said he was not at the hospital when Harvey was given the overdose but was called in soon afterward.

“‘This is the first death that I can remember that has happened in the emergency department as a consequence of a medication error,” said McDermott, who has been with Mayo Hospital for 17 years and also serves as president of the Maine Medical Association, and he wants it to be the last.

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