October 5, 1996 in Nation/World

Kmc Patient Given Overdose Hospital Admits Mistake That Could Have Cost Man His Life

By The Spokesman-Review
 

Tom Porinchok didn’t wake up in his recovery room at Kootenai Medical Center early Tuesday.

He couldn’t.

During the night a nurse accidentally put a potent dose of morphine in his intravenous bag - possibly enough to kill him.

Hospital officials admit mistakes happen occasionally in administering medication, but rarely are they this serious.

When a nurse and Porinchok’s wife tried to rouse him at 3:30 a.m., he didn’t respond, said Nancy Porinchok.

“I said, ‘Tom, Tom, open your eyes,”’ his wife recalled Friday. His eyelids opened a crack, “and his eyes were rolled back in his head.”

The emergency room doctors who responded treated him successfully for an overdose. Porinchok finally woke up in the intensive care unit with tubes down his throat.

“I was scared when I woke up,” he said Friday from his hospital bed. “I couldn’t talk. I was strapped down. When they gave me drugs to counteract it (the morphine), I guess you go into convulsions.

“That’s what I hear. I don’t remember anything.”

Porinchok is expected to be discharged today. Although he spent a day in the intensive care unit, hospital officials don’t believe his stay was extended as a result of the mistake.

Porinchok, 47, was admitted Monday to have surgery to remove tumors in his intestines.

Fearing the tumors could be cancerous, the Porinchoks married on Sept. 16.

“The doctor said there was a big possibility of cancer,” Nancy Porinchok said. “We wanted me to be able to have the say, and have the right to be with him.”

The surgery went well, and the tumors were benign. Nancy Porinchok spent the night in his recovery room anyway, and she’s glad she did.

A nurse changed the medication on the intravenous tube about 1:30 a.m., she said.

When she was getting ready to leave at 3:30 a.m., because she had to get home and get ready for work in Spokane, she found her husband cold and clammy.

She asked a nurse to check his blood pressure, and that’s when the problem was discovered, she said.

“I just about lost him,” Nancy Porinchok said.

The nurse administered the wrong strength of morphine. KMC vice president of patient care Carmen Brochu said it happened as a result of a breakdown in procedure.

The nurse was asked to review her procedures and take part in the recovery of the patient, but she was not disciplined.

“She’s going to be her own worse discipline,” Brochu said.

The Porinchoks said the nurse and hospital were extremely apologetic, and hospital officials offered to cover any additional costs that accrued because of the visit to the intensive care unit.

“They were shook up about it, too,” Porinchok said.

Just the same, Porinchok said he has nervously watched every new dose of medication he’s been given.

Brochu said the incident should not make patients and their loved ones hesitant about care at KMC.

“We administer such a large number of medications and we have so few errors,” she said. “If they have any concern at all, they can be very involved in the administration of the medication….They can have as much control as they want.”

, DataTimes MEMO: This sidebar appeared with the story: BY THE NUMBERS KMC Vice President of Patient Care Carmen Brochu said the hospital administers on average 81,000 doses of medication each month. Of those, an average of 31 mistakes are made. Fifty percent of the mistakes are in timing, and about 40 percent are a failure to give the medication. Only in 5 percent of the errors is the patient given the wrong medication, Brochu said. “This is the first incident in years that has actually affected a patient,” Brochu said. “I looked back over several years, and we haven’t had one.”

This sidebar appeared with the story: BY THE NUMBERS KMC Vice President of Patient Care Carmen Brochu said the hospital administers on average 81,000 doses of medication each month. Of those, an average of 31 mistakes are made. Fifty percent of the mistakes are in timing, and about 40 percent are a failure to give the medication. Only in 5 percent of the errors is the patient given the wrong medication, Brochu said. “This is the first incident in years that has actually affected a patient,” Brochu said. “I looked back over several years, and we haven’t had one.”


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