Drug Topics - October 22, 2007 - (Page H11)

www.drugtopics.com OCTOBER 22, 2007 DRUG TOPICS HSE 11 Professional Practice > > > Man given fatal drug overdose at Staten Island hospital Michael Barbella A fter learning her son, Jason Cruz, had been in a car accident, Lillian Latimer rushed to his bedside at Staten Island University Hospital. There, she found him with a breathing tube in his nose and a surgical trauma team ready to repair the fracture to his left arm. The hospital’s medical staff reassured Latimer that her son’s injuries were not life-threatening. Later that day, however, Latimer was stopped by a member of the hospital’s medical team and told that he had slipped into a coma. He died nearly three weeks later. Cruz’s family was devastated. For months, they wondered how the healthy, 28-year-old construction worker could slip into a coma and die from a broken arm. Though they had no proof, they suspected Staten Island University Hospital was at fault. The New York City Medical Examiner’s Office and New York State Department of Health recently confirmed the family’s suspicions. Cruz, the father of a fiveyear-old girl, died from an overdose of fentanyl, a painkiller used most often in operating rooms and on critically ill or injured patients. The medical examiner’s office determined the overdose to be accidental and said Cruz died from anoxic encephalopathy—a shortage of oxygen to his brain—triggered by acute fentanyl intoxication. “The dosage he was prescribed was not the dosage he received,” said Ellen Borakove, spokeswoman for the medical examiner’s office. The dosage he received was five times the prescribed dose, according to the results of a New York State Department of Health investigation. Cruz received the excessive amount of fentanyl for 23 minutes, the investigation revealed. “Fentanyl is a very potent narcotic,” said Michael Cohen, R.Ph., president of the Institute for Safe Medication Practices in Huntingdon Valley, Pa. “With the injectible, the dose is measured by microgram and it often gets confused with milligram. ” Cruz a one-time dose of 50 mcg of fentanyl, to be given through an IV pump, the “With the injectible state investigation concluded. [fentanyl], the dose is A nurse discontinued the propofol, and early that measured by microgram evening, the surgical resident and it often gets confused wrote an order to discontinue the fentanyl, state health docu- with milligram.” ments show. At 6:40 P.M., nurses reported that Cruz was Michael Cohen, R.Ph., president of the Institute alert and responding to com- for Safe Medication Practices mands, but less than an hour later, he was unresponsive, his heart rate had slowed to less than 60 beats per minute, and the oxygen levels in his blood were dangerously low. A nurse restarted Cruz’s dose of fentanyl at 6:54 P.M. without an order, and mistakenly gave him 20 mcg/hr for 18 minutes. After Cruz died, the hospital offered to help pay for his funeral. The gesture, however, hasn’t deterred Cruz’s family from moving ahead with plans to file a wrongfuldeath lawsuit against SIUH. John G. O’Leary, a Staten Island attorney representing Cruz’s family, did not return repeated phone calls for comment on the status of the lawsuit. John Demoleas, a spokesman for SIUH, declined to comment on the pending lawsuit or circumstances surrounding the overdose, saying, “It’s a tragedy and our heartfelt feelings go out to the family, but we are not discussing the case whatsoever.” Failures found The state investigation uncovered a number of failures among SIUH’s nursing and medical staff. It found that, besides administering an incorrect dose of fentanyl, the nursing staff also failed to document significant patient observations or Cruz’s responses to treatment. The hospital’s medical staff did not document its rationale for administering fentanyl to Cruz, and did not document its plans to extubate the patient, the investigation found. In addition, the state discovered that the ICU’s central telemetry station—which allows the medical staff to monitor patients’ vital signs without having to be in the room—was vacant around 7 P.M., when Cruz’s vital signs were falling. The station was vacant due to staff dinner breaks and a change of shift rounds, the investigation revealed. The lethal dose Cruz was wheeled into the emergency room of Staten Island University Hospital (SIUH) after crashing his SUV into a brick wall and steel guardrail on the morning of Jan. 19. He was given 40 mcg/min of propofol (Diprivan, AstraZeneca) and transferred to the hospital’s surgical intensive care unit, according to the state investigation. Later that afternoon, a surgical resident ordered that Cruz be given 4 mcg/hr of fentanyl. The resident also prescribed http://www.drugtopics.com

Table of Contents Feed for the Digital Edition of Drug Topics - October 22, 2007

Drug Topics - October 22, 2007 Contents Latebreakers Legislative Victory Builds Momentum for Pharmacy Month Letters Health-System Edition R.Ph.s Brace for Payment Denial for Hospital-Acquired Conditions Topical Human Thrombin Helps Arrest Bleeding FDA Panels Fail to Set Target Levels for Renal Patients’ Hemoglobin Warning Letters Raise Patient Safety Concerns for Fentora Ending/Reversing Weight Gain Man Given Fatal Drug Overdose at Staten Island Hospital Pharmacists Playing More Important Role in Dialysis Treatment AHA President R.Ph.'s Here's How You Can Increase Your Value Premier Launches Comprehensive Quality Improvement Project FDA Approves Dexrazoxane for Treatment of Extravasation New Federal, State Reforms to Ease Disaster Relief Kinks 150 Years of American Pharmacy Ten Tips for MTM Success Independent Superstars: The Ones to Watch The New Dynamic Duo A Parkinson's Disease Primer Classified New Products Advertisers Index Viewpoint

Drug Topics - October 22, 2007

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