http://www.tri-cityherald.com/news/local/article31786419.html
August 20, 2010
By Sheila Hagar, Walla Walla Union-Bulletin
WALLA WALLA -- A Washington state Department of Health investigation
found procedural problems at Providence St. Mary Medical Center in a
death that Walla Walla County Coroner Frank Brown has listed as a
medical homicide.
The department launched its investigation when a caller to the state's complaint hotline alleged that a 60-year-old patient at the hospital died March 1 of accidental acute morphine overdose. The caller, who is not named in the report, pointed to a forensic pathologist's autopsy, health officials said.
Brown labeled the death "medical homicide," a decision agreed with by Dr. Carl Wigren, the forensic pathologist who performed the autopsy. Wigren is paid by the county for his services.
The man died so quickly after being hospitalized for respiratory distress, Wigren said from his office in Seattle, that he and Brown were concerned about a possible H1N1 influenza victim. An autopsy was ordered to address the possibility of a significant contagion and threat to public health.
Wigren took a swab of the man's airway and, as a matter of routine, turned blood samples over to the Department of Health's Shoreline-based lab. "I like to submit all my cases for toxicology because sometimes you get a surprise. And, obviously, this was a surprise."
Lethal dose
The level of morphine found in the deceased man was lethal, which falls under the definition of medical homicide, the pathologist said.
In a prepared statement, Wigren said Brown's ruling on the matter came after "he carefully considered the totality of the evidence, including the toxicology report, and the hospital's medical records and appropriately applied the medical definition of homicide as death resulting from an intentional or volitional act of one person against another. As coroner, Frank's job is to assign a manner of death. It is not a legally binding opinion and does not necessarily imply criminal intent. It is the responsibility of other agencies to follow up and investigate."
Wigren, who is required by law to report his findings, notified the Washington state Quality Assurance Board and Walla Walla Adult Protective Services after consulting with a palliative-care specialist at Harborview Medical Center in Seattle.
Because the patient was on end-of-life, or palliative, care, the allegation of medical homicide does not apply and was not substantiated at the level of the state's Health Systems Quality Assurance office, according to an investigation conducted by Department of Health.
'Things went wrong'
Nonetheless, things went wrong in the case on several key points, despite St. Mary having proper policies and procedures in place, noted Linda Foss, executive director of clinical care facilities at the state Department of Health.
Her staff is in charge of investigation and inspection of clinical care facilities, checking for compliance for federal Medicare and state regulations. At the helm of that department for eight years, Foss said this has been an unusual case.
The particulars in this death are "a new issue" to Foss, one her staff did not find in other charts of patients in similar situations, the department head said.
At issue is a failure by staff to follow protocol, according to the state. The patient was admitted to St. Mary on March 1 with pneumonia. After determining that end-of-life care was desired by the patient and his family, the attending physician wrote an order for one milligram of morphine to be administered intravenously continuously after a two milligram injection directly into the vein. The IV drip was ordered adjusted for the patient's comfort and respiratory distress.
No limits given
There was no specific range -- or dosage -- or incremental increases identified in the order, nor was a maximum dose or "no limit" written, despite established policies at St. Mary.
That's a problem, Foss said, "It makes no difference if it is end-of-life or other. Any drug given in a hospital, there is a range on that. And it should be applied to any patient."
The hospital's pharmacy then filled the order without contacting the physician for clarification. Nursing staff proceeded to administer the morphine, also without seeking input from the doctor.
Nurses' notes indicated the drip rate on the patient was initiated at two milligrams per hour, "and was increased to 60 mg/ph in less than 3 hours," the report notes. "Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate."
The investigator's interviews with hospital staff -- including the chief nursing officer, quality assurance director, nurse practitioner and registered nurse in charge of the patient -- confirmed the amount, rate and increase of the medication given to the patient were within normal ranges for comfort care.
However, staff also agreed the doctor's order lacked enough information and that not all physicians write palliative orders at St. Mary in accordance with approved policies, noted the state's report.
As well, nursing and pharmacy staff "did not consistently ask for clarification prior to medication and administration to the patient."
And while the family of the deceased may have agreed to the plan of action, "they don't know about titrating drugs," Foss said. "They just know they have come to terms with it."
As the set of regulatory "eyes," she sees this as leadership failure at St. Mary, she explained. "I'm a straight shooter and I call it as I see it."
The hospital should be holding doctors and nurses accountable for following procedures, Foss said. "They are not bad people, but they got into sloppy practices."
St. Mary officials declined comment, referring questions to the hospital's attorney, David Robbins, who said the hospital does not respond to pending matters of this nature and pointed out he has previously described Brown's finding as "inaccurate and without basis."
Health citations
The Department of Health issued St. Mary citations for deficient practices related to Medicare and state licensing regulations, but that is where her department stops, Foss said. "We never make a statement (regarding cause of death) because we don't know."
Neither does her office have authority to levy fines, she explained.
Her job, instead, is to identify the problem, ask the questions and make sure procedures are in place and followed, Foss added. "If it's in writing, you better do it and you better know it. I'm expecting you to know it. St. Mary should know better."
The case was brought to the attention of the Walla Walla Police Department by the state Department of Health, prompting an investigation by detectives. Police Chief Chuck Fulton said the department is waiting for additional information from a related investigation by the state.
-- Reporter Andy Porter contributed to this story.
The department launched its investigation when a caller to the state's complaint hotline alleged that a 60-year-old patient at the hospital died March 1 of accidental acute morphine overdose. The caller, who is not named in the report, pointed to a forensic pathologist's autopsy, health officials said.
Brown labeled the death "medical homicide," a decision agreed with by Dr. Carl Wigren, the forensic pathologist who performed the autopsy. Wigren is paid by the county for his services.
The man died so quickly after being hospitalized for respiratory distress, Wigren said from his office in Seattle, that he and Brown were concerned about a possible H1N1 influenza victim. An autopsy was ordered to address the possibility of a significant contagion and threat to public health.
Wigren took a swab of the man's airway and, as a matter of routine, turned blood samples over to the Department of Health's Shoreline-based lab. "I like to submit all my cases for toxicology because sometimes you get a surprise. And, obviously, this was a surprise."
Lethal dose
The level of morphine found in the deceased man was lethal, which falls under the definition of medical homicide, the pathologist said.
In a prepared statement, Wigren said Brown's ruling on the matter came after "he carefully considered the totality of the evidence, including the toxicology report, and the hospital's medical records and appropriately applied the medical definition of homicide as death resulting from an intentional or volitional act of one person against another. As coroner, Frank's job is to assign a manner of death. It is not a legally binding opinion and does not necessarily imply criminal intent. It is the responsibility of other agencies to follow up and investigate."
Wigren, who is required by law to report his findings, notified the Washington state Quality Assurance Board and Walla Walla Adult Protective Services after consulting with a palliative-care specialist at Harborview Medical Center in Seattle.
Because the patient was on end-of-life, or palliative, care, the allegation of medical homicide does not apply and was not substantiated at the level of the state's Health Systems Quality Assurance office, according to an investigation conducted by Department of Health.
'Things went wrong'
Nonetheless, things went wrong in the case on several key points, despite St. Mary having proper policies and procedures in place, noted Linda Foss, executive director of clinical care facilities at the state Department of Health.
Her staff is in charge of investigation and inspection of clinical care facilities, checking for compliance for federal Medicare and state regulations. At the helm of that department for eight years, Foss said this has been an unusual case.
The particulars in this death are "a new issue" to Foss, one her staff did not find in other charts of patients in similar situations, the department head said.
At issue is a failure by staff to follow protocol, according to the state. The patient was admitted to St. Mary on March 1 with pneumonia. After determining that end-of-life care was desired by the patient and his family, the attending physician wrote an order for one milligram of morphine to be administered intravenously continuously after a two milligram injection directly into the vein. The IV drip was ordered adjusted for the patient's comfort and respiratory distress.
No limits given
There was no specific range -- or dosage -- or incremental increases identified in the order, nor was a maximum dose or "no limit" written, despite established policies at St. Mary.
That's a problem, Foss said, "It makes no difference if it is end-of-life or other. Any drug given in a hospital, there is a range on that. And it should be applied to any patient."
The hospital's pharmacy then filled the order without contacting the physician for clarification. Nursing staff proceeded to administer the morphine, also without seeking input from the doctor.
Nurses' notes indicated the drip rate on the patient was initiated at two milligrams per hour, "and was increased to 60 mg/ph in less than 3 hours," the report notes. "Documentation of the patient's symptoms did not include pain assessments, and only brief descriptions of respiratory effort and heart rate."
The investigator's interviews with hospital staff -- including the chief nursing officer, quality assurance director, nurse practitioner and registered nurse in charge of the patient -- confirmed the amount, rate and increase of the medication given to the patient were within normal ranges for comfort care.
However, staff also agreed the doctor's order lacked enough information and that not all physicians write palliative orders at St. Mary in accordance with approved policies, noted the state's report.
As well, nursing and pharmacy staff "did not consistently ask for clarification prior to medication and administration to the patient."
And while the family of the deceased may have agreed to the plan of action, "they don't know about titrating drugs," Foss said. "They just know they have come to terms with it."
As the set of regulatory "eyes," she sees this as leadership failure at St. Mary, she explained. "I'm a straight shooter and I call it as I see it."
The hospital should be holding doctors and nurses accountable for following procedures, Foss said. "They are not bad people, but they got into sloppy practices."
St. Mary officials declined comment, referring questions to the hospital's attorney, David Robbins, who said the hospital does not respond to pending matters of this nature and pointed out he has previously described Brown's finding as "inaccurate and without basis."
Health citations
The Department of Health issued St. Mary citations for deficient practices related to Medicare and state licensing regulations, but that is where her department stops, Foss said. "We never make a statement (regarding cause of death) because we don't know."
Neither does her office have authority to levy fines, she explained.
Her job, instead, is to identify the problem, ask the questions and make sure procedures are in place and followed, Foss added. "If it's in writing, you better do it and you better know it. I'm expecting you to know it. St. Mary should know better."
The case was brought to the attention of the Walla Walla Police Department by the state Department of Health, prompting an investigation by detectives. Police Chief Chuck Fulton said the department is waiting for additional information from a related investigation by the state.
-- Reporter Andy Porter contributed to this story.
