Medication Errors
Zenker's proves to be lethal libation
Biopsy solution is confused with orange juice
A few months ago a California hospital patient mistook a glass of Zenker's solution for orange juice, drank it, and was dead within two hours. The woman's death triggered a response from the Oakbrook Terrace, IL-based Joint Commission on the Accreditation of Healthcare Organizations.
"We went out to the organization on Feb. 26 and 27 to do a special survey," says Julia Roberts, Joint Commission spokeswoman. The findings from that visit were processed and sent to the accreditation committee as this issue of Hospital Peer Review went to press. Laura Sarff, RN, CPHQ, quality improvement (QI) department director for the Los Angeles County (CA) Health Department, says the Joint Commission was pleased with the hospital's root-cause analysis. Nevertheless, the episode could result in discipline against the hospital or a curtailment of its Medicare and Medi-Cal funding, Assistant Health Services Director Donald C. Thomas told the Los Angeles Times shortly after the incident.
Resident places solution within reach
The 52-year-old woman had entered Martin Luther King Jr./Drew Medical Center in Lynwood, CA, because she had lost weight and suffered from anemia. Once in the hospital, she was diagnosed with kidney disease and underwent dialysis hours before the incident.
While she was in another part of the hospital getting a sonogram, a resident placed the Zenker's solution on her nightstand in preparation for a scheduled bone marrow biopsy to determine the presence of cancer relating to the patient's kidney problem. Zenker's solution, a highly toxic fixative used for biopsies and containing formaldehyde, mercuric chromide, and potassium bichromate was in what investigators called a benign-looking specimen container. The procedure was called off sometime before the woman drank the solution, and representatives of the facility had no comment on whether the resident had been informed of the change.
When the woman was returned to her room, medical staff did not remove the biopsy tray. After drinking the solution, the patient vomited and precipitated a code blue response. She went into cardiac arrest and died.
JCAHO uses clipping service
Zenker's solution has to be at bedside during the biopsy procedure, explains Sarff. "It's used to preserve biopsy tissue, and the tissue needs to travel quickly between the biopsy site and the solution."
The Joint Commission's new sentinel event policy began on April 1, and its protections regarding voluntary reporting were not in effect at the time of the Zenker's incident. Hospital Peer Review asked Sarff how the Joint Commission learned of the incident, because King/Drew did not voluntarily report it.
"The Joint Commission subscribes to a [periodical] clipping service," she says. That's what prompted the call to the hospital's CEO. It's Sarff's opinion that the Joint Commission "is not completely up to speed with its sentinel event policy. It's new, and they're just training their surveyors now.
"In a conference I attended, representatives of the Joint Commission said they would keep track of sentinel events and look at them again when they came for their regular survey," she says. "Then all the information would be fed through their accreditation committee." King/Drew underwent its triennial survey in May.
Sarff says the incident prompted the staff to review how they handle toxic substances systemwide. They asked, "What are the procedures? What kinds of toxic substances need to make their way to a patient's bedside? Should they ever be taken out of the lab setting? How do we monitor those that are? How do we make sure something like this doesn't happen again?" Sarff oversees QI efforts in six hospitals and several urgent care centers, and she says all of the facilities reviewed their policies and procedures to ensure they have some of the critical elements in place, like proper labeling of toxic solutions.
Zenker's gets skull and crossbones
"For example, containers with solutions like Zenker's now have to have skull-and-crossbones designations," Sarff says. "We initiated specific systemwide logging procedures whereby the solution is kept only in designated laboratories. It's checked out by an individual just prior to being needed at the bedside. We looked at those procedures not just for King/Drew but for others in the system as well."
King/Drew officials say the hospital's position is that the incident has highlighted problems that need to be corrected. "Certainly this is a very tragic event that we must and have learned from," King/Drew administrator Randall Foster told the Los Angeles Times following the incident. The facility has implemented a series of reforms aimed at preventing a recurrence.
"As we have more integrated delivery systems, it's going to be really important for folks at the corporate level to look at all the hospitals they're involved in," Sarff continues. "Errors that occur at one facility can certainly occur somewhere else. It's important to change processes to prevent recurrences, and we're very committed to doing that here."
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