State takes no action in death at Mayo Regional Hospital

Posted Aug. 26, 2010, at 9:02 p.m.
Last modified Jan. 29, 2011, at 11:37 a.m.

DOVER-FOXCROFT, Maine — The Maine Department of Health and Human Services has decided to take no action after concluding its investigation into the death of a Mayo Regional Hospital patient who mistakenly received a massive drug overdose on June 4 while under the hospital’s care.

Anne Flanagan, assistant director of DHHS’s Division of Licensing and Regulatory Services, said Thursday that the facts surrounding the death were substantiated but no findings were made because the corrective action plan the hospital put in place after the death is working.

Flanagan confirmed Thursday that a team of DHHS acute care officials had visited Mayo Regional Hospital on July 16 to review the circumstances surrounding the death of Timothy Harvey, 51, of Atkinson.

Harvey had gone to the emergency room with symptoms of anaphylaxis that included facial swelling and some thickening of the tongue. Emergency room employees gave him 0.3 milligrams of epinephrine, an appropriate amount, and he showed signs of improvement, hospital officials confirmed in June.

While Harvey was held for observation, he began to show some of his earlier symptoms, so a second dose of epinephrine, a synthetic form of adrenaline, was given to him, according to Mayo Hospitalist Dr. Tom Murray. When the patient began to experience chest pain and shortness of breath later that night, a Mayo staff member reviewed his chart and realized Harvey had mistakenly been given 10 times the normal dosage of epinephrine, Murray said. The overdose ultimately caused Harvey to collapse and die, despite vigorous efforts to revive him, he said.

After Harvey’s death, the hospital conducted a root-cause analysis that prompted several changes. Vials of epinephrine were removed from the emergency rooms and replaced with EpiPens, Tom Lizotte, the hospital’s marketing and development director, said Thursday.

In addition, epinephrine was added to a list of high-risk medications that require a double-check. In other words, Lizotte said, one nurse cannot receive an order from a physician and administer a medication with double-checking with a second staff member.

The hospital also now subscribes to an electronic version of medication practice updates furnished by medical journals rather than waiting for a printed version.

The hospital’s own in-house investigation resulted in no discipline or firing of those responsible for mistakenly giving Harvey the massive overdose of medication.

“It’s largely a case of human error, and punishing people after the fact is not the approach that is recommended in this case,” Lizotte said earlier. “You want people to step forward when mistakes are made so that they can report these things, and if you don’t do that, then you have a chilling effect on other people coming forward.”

The fact the hospital took the unusual step of publicly releasing the details involving the death was commended in June by Catherine Cobb, DHHS’s director of the Division of Licensing and Regulation Services, who said hospitals don’t typically publicize such deaths.

Lizotte said he had no comment Thursday about any financial settlement with the family. “That is between the insurance company and the family themselves,” he said.

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