A California patient died after a nurse unintentionally injected them with as much as 8,000 times the prescribed dosage of a blood pressure medication, a new report reveals.
The nurse hadn't checked the IV package or the patient's current blood pressure.
She injected them with a concentrate of Levonphed, a powerful drug used to treat life-threateningly low blood pressure.
In violation of the hospital's policy the nurse, who had never administered the drug, was not overseen or accompanied by anyone and before she had even pushed the full dose, the patient's heart stopped.
The hospital, Vibra Hospital of Sacramento is one of seven California hospitals facing fines of as much as $75,000 for mistakes that cost patients their lives.
After heart disease and cancer, medical errors are the third leading cause of death in the US.
When patients wind up in the hospital, they are often already facing a medical emergency, and health care providers are scrambling to figure out what's wrong and what the best course of treatment is.
But many of these errors are not judgement issues, but rather the results of system errors, poor training, or plain oversight and carelessness.
These mistakes cost somewhere between 250,000 and 440,000 people their lives every year (depending on who is counting and how they are counting).
A recent Johns Hopkins University study found that it is not so much individual bad doctors or nurses, but failure in systems and safety nets that lead to these deaths.
In the case of the Vibra patient, there were several failures that suggested the nurse had not been properly trained or overseen and the hospital hadn't adhered to simple policies like proper labeling that might have prevented the deadly disaster.
The nurse came in to give the patient their daily 9am medications, which included an IV drip of Levophed diluted in 250mL IV drip.
She had never given the drug to a patient before, was not familiar with it and told the California Department of Public Health that she didn't check the touch screen monitor attached to the IVs for instructions.
Nor did she check the patient's record to see that the doctor had instructed Levophed to only be administered if the patient's average blood pressure was below 65, the nurse admitted.
Nevertheless, she retrieved the vial of concentrated Levophed from a drawer in the medications room. Despite the potent vials in it, the drawer did not have a warning to that effect, though one of the several laptop screens she had to consult in the medications room warned that Levophed needed to be diluted.
All the while, just across the room, the prepared pack of diluted Levophed the patient was meant to get was in the refrigerator on the other side of the room.
But no one alerted the nurse. According to the long-term care hospital's policy, a second nurse was suppose to sign of on the medication, too, but didn't.
The nurse pushed the concentrated drug into the patient's IV, sending 3,000 to 8,000 times the dose of Levophed coursing through the patient's veins.
Levophed is a powerful vascular constrictor which causes veins to tighten up, pumping blood more quickly to various parts of the body.
Before the nurse had even finished pushing the IV medication, the patient's heart was overwhelmed their heart. Less than half an hour after the nurse had entered to give them their medications, the patient was dead.
'The department determined the facility failed to administer a medication as prescribed by the physician or in accordance with facility policy,' the California Department of Health wrote in its report.
'It also failed to develop and implement policies and procedures for establishment of a safe and effective system for the storage, dispensing, and use of drugs.'
According to a statement released last month, Vibra has since put all of its warning signs in all capital letters, moving vials of concentrate out of their accessible locations and shutting down the whole ICU where the patient died until all of the nurses there had been properly trained on how to safely give medications.
Vibra was fined $75,000 over the patient's death, but did not issue a statement and could not be reached for comment.