Legal Community and Review-Milk infused into baby's central line: $7.18 million
By Pearl Schaikewitz, JD
Legal Consultant, Atlanta
News: The parents of a brain-damaged baby have reached a $7.18 million settlement with the hospital where the child was injured. The mishap occurred when a temporary float nurse infused breast milk into the baby's central line instead of her abdominal feeding tube.
Background: The infant was born in April 1996 without complications. Her Apgar scores were seven and nine. She had difficulty feeding and was unable to suck or swallow. A cranial ultrasound and CTs were performed, with normal results. The infant continued to lack suck or swallow reflexes, and an apparent seizure was noted. An EEG had abnormal findings, but the results of an MRI were normal.
The baby was fed through a nasal gastric tube and discharged at the age of 2 weeks. Diagnostic tests did not uncover the source of her ongoing inability to suck or swallow. A feeding tube was placed in the baby's abdominal wall in May. However, it did not provide sufficient nutrition, and a catheter was inserted into her right jugular vein to allow for additional feeding.
When the child improved, the central line was discontinued and nutrition was administered through the abdominal feeding tube. The day the baby was supposed to be discharged, the feeding tube was removed and the parents were allowed to take her out for a walk. They were gone for several hours. When the parents returned the baby to her room, her primary pediatric nurse was on a lunch break. A temporary float nurse reattached the feeding tube and restarted breast milk feeding. However, the breast milk adaptor was attached to the central line, and milk was infused into the baby's jugular vein.
When the pediatric nurse returned, she stopped the infusion immediately, but milk emboli already had blocked the blood supply to numerous portions of the brain. The infant developed seizures and went into a coma. A bacterial infection developed, but the child began to recover and was discharged in late June 1996. CT scans confirmed a devastating injury. The child had some paraplegia and cognitive deficits but was able to stand with some assistance as of March 1999. Her suck and swallow deficit did not improve until that time.
What it means to you: "The baby in this case had both a tube going into her stomach and a tube going into her jugular vein. The breast milk was in a bag hanging on the pole. Unless the health care provider traces the line from the pole, it is possible to hook up the line into the wrong port," says Georgene Saliba, RN, BSN, FASHRM, HRM, director of claims/risk management for Lehigh Valley Hospital and Health Network in Allen town, PA.
That is what can happen when the health care provider does not look to see where the line is ultimately going. "Unless you trace the line up to the bag and down to the port where it connects, you can make this mistake. You think the line you have in your hand is the correct line. You think you are connecting to what you believe is the correct thing in your other hand. When in actuality, as happened in this case, you have in your hand the tubing that goes to the jugular vein instead of to the stomach," Saliba says.
This is a systems issue as well as one of basic nursing principles, she says. She suggests these types of incidents can happen if you have the same type of connecting adaptor at the end of the each line: both a leurlock or a slip lock. "Humans make mistakes. If the tubing looks exactly the same, the lines are not color-coded, and the connectors are the same, that error can happen."
To reduce the possibility of this type of error, a facility can create "fail-safes," Saliba advises. "You can color-code the tubing, like putting blue tape on both ends of one line and green tape on both ends of the other line, so you know that blue and green cannot go together. Or you can change the color of the tubing or the type of adapter on it. Of course, proper nursing means that you should know the port of administration. But if you have a system that allows the error to be made, you need to look at how you can improve the system and prevent a reoccurrence. The system should not allow the health care provider to attach the 'wrong' solution to the wrong port. The result of such an event can be devastating, as it was in this case."
Reference
Anonymous settlement, King County (WA) Superior Court.
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