Woman dies after hospital injection error
SEATTLE – An Everett woman who underwent surgery at a Seattle hospital to repair a brain aneurysm died after she was mistakenly injected with a highly toxic antiseptic solution, a television station reported.
Mary McClinton, 69, had the operation Nov. 4 at Virginia Mason Medical Center. She died Tuesday.
The medical center has apologized for the error, sent out a detailed staffwide memo about exactly what happened, and retrained staff and changed its procedures in an effort to prevent a similar mistake in the future.
“We can’t apologize enough for this preventable tragedy,” Dr. Robert Caplan, Virginia Mason medical director and physician leader for patient safety, told KING5 TV.
In a statement posted Tuesday on its Web site, the hospital said, “Recently, a preventable medical error occurred at Virginia Mason that we believe caused the death of one of our patients.
“We have offered our heartfelt apologies to the family of the patient and are doing everything we can to help them in this time of grief. But perhaps the only way we can make our apology real is to do everything we can to prevent medical errors in our system.”
At the end of McClinton’s operation, a technician was supposed to inject a harmless marker dye used for X-rays into a leg artery, KING reported. Instead, the syringe was filled with chlorhexidine, a toxic antiseptic.
Over the next two weeks, the woman deteriorated, suffering through a leg amputation, a stroke and multiple organ failure until she died.
After the operation, “Things were looking good, but in reality, when that plunger was pushed, my mother’s fate was sealed,” Gerald McClinton, one of Mary McClinton’s sons, told KING.
A staffwide memo that hospital spokeswoman Kim Davis said was sent on behalf of CEO Gary Kaplan was sent out before McClinton died and spelled out in detail what went wrong.
“We have injured her so badly that she may never regain the life she enjoyed,” the memo read, because of “an avoidable mistake that caused massive chemical injury.”
Dr. Robert Caplan said that “while no single person is responsible, all of us are responsible.”
The technician, who was not identified, was taken off duty and retrained, along with the entire medical staff.
The hospital’s investigation concluded the issue was not carelessness but a system that allowed two clear solutions to be confused.
Virginia Mason had recently switched from using a brown iodine antiseptic to a colorless version that was better at killing germs, KING reported. But the marker dye is also clear and the syringe was filled from an unlabeled cup containing the antiseptic instead.
Caplan said the hospital has changed the system so the two solutions are never put on the same table during a procedure.
Steven McClinton, another of Mary McClinton’s sons, called the hospitalwide memo “a very strong piece of paper written by a really wonderful doctor who feels just as strongly about this as we do.”