Hospital error caused death

By Sara Jean Green
Seattle Times staff reporter

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A Seattle-area woman died early yesterday, two weeks after she was accidentally injected with a toxic cleansing solution during a medical procedure at Seattle's Virginia Mason Hospital.

"We're just so sorry and so devastated this happened," Dr. Robert Caplan, the hospital's director of quality, said late last night. "It's a very unfortunate error that we all feel horrible about."

About two weeks ago, the woman came to the hospital "for a sophisticated procedure" in the radiology department, Caplan said. A technician was to inject the woman with contrast dye to show how her therapy was progressing, but instead, the woman was injected with a toxic antiseptic, he said.

Almost immediately, hospital staff realized something was wrong and activated the hospital's "patient safety alert system," Caplan said. Everyone involved in the case was immediately taken off duty.

"The cleansing solution basically acted as a poison, which caused widespread damage to the organs of her body," Caplan said. The damage "couldn't be remedied or reversed, even through aggressive treatment," including amputation of one of the woman's legs, he said.

He declined to discuss details last night because of federal laws protecting patient privacy.

The woman died just after midnight, but as of last night, her name had not been released by the King County Medical Examiner's Office.

In a statement posted on its Web site yesterday, hospital officials 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," the statement says.
 
Citing a 1999 report, the statements says 98,000 Americans die each year from medical mistakes.

Caplan said the accidental injection already has led officials to make hospital-wide changes. For instance, the liquid antiseptic has been removed from the hospital. "It now comes as a swab on a stick," making an accidental injection impossible, he said.

"What we're really striving to do is to find the lesson from this mistake," Caplan said. "The only way we can make medicine safer is if we face up to these errors and openly investigate them."

Sara Jean Green: 206-515-5654 or sgreen@seattletimes.com