Failure to Understand Allergy Leads to Woman’s Death

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Communication is essential between health care providers – but sometimes communication fails because of the arrogance or carelessness of the persons involved in the needed medical communication. The following video interview and true story illustrate an extreme case of what may happen when communication fails.

Several years ago, a female client about to enjoy an important anniversary was admitted to a University affiliated hospital for the purpose of having a colostomy wound debrided (cleaned up).

This was to be a one-day inpatient hospital procedure and was associated with little to no risk. As a part of the procedure, however, a prophylactic antibiotic was to be administered.

Unfortunately in this particular case, when the antibiotic (Cefotan) was administered the patient suffered a sudden cardiac arrest. This cardiac arrest resulted from a rare but well-known allergic reaction to this antibiotic. The patient was successfully resuscitated.  No harm done.  A substitute antibiotic was employed uneventfully.  Because the patient suffered a cardiac arrest before her surgery could be performed,  the procedure was rescheduled to occur approximately thirty days later with the same surgeon who had earlier been involved.  The anesthesiologist, who had saved this patient’s life earlier,  recorded in the order sheet, in the progress notes and even in a typed signed note provided to the patient, notice of what had happened to her, “You are allergic to the drug Cefotan. Don’t allow this drug to be administered to you. You may die.” Who could have done more to protect the patient from a similar future occurrence?

The patient showed her surgeon the note her anesthesiologist had provided and,  rather than openly disagreeing with the note, he simply said he was aware of that.

Thirty days after the patient’s original cardiac arrest she was readmitted for a repeat of the same procedure that was originally planned. The patient had ugly premonitions about what might happen which she shared with the admitting nurse. The admitting nurse was sufficiently concerned that she assured the patient that an anesthesiologist would attend the patient before the patient went to the operating room to ease the patient’s mind. The anesthesiologist who came to the patient’s side assured the patient that everyone knew she was allergic to Cefotan.   She said reasuringly,”You will not receive Cefotan.”   Were she to receive Cefotan she might die.   The wristband the patient was wearing revealed the presence of this allergy as did numerous references in the hospital records that no one could possibly miss. The anesthesiologist promised the patient, “You will not receive this drug.”

Notwithstanding all these assurances the patient went to the operating room for her one-day procedure and as the same anesthesiologist entered the room who had just offered such reassuring promises, this anesthesiologist observed the patient was about to receive a prophylactic antibiotic intravenously. The anesthesiologist promptly inquired as to the type of antibiotic and was told, “Well its  Cefotan.” The anesthesiologist replied, “But she is allergic to that.”

Amazingly, the surgeon present, who was the same surgeon present at the time of the original cardiac arrest, insisted that the patient get the prophylactic antibiotic and the anesthesiologist present and the nurse anesthetist present lacked the courage to refuse.  Instead the anesthesiologist said to the nurse anesthetist, Well, make sure you don’t give to much.”  The drug was administered.  The patient died.

These facts are taken from a real case. Agreements and legal restrictions prevent the identification of names and places or even institutions.

The case was concluded in such a way that all involved were aware of their involvement and what they did, how it contributed to the patient’s death and what should have been done otherwise.   It is not always possible to prevent malpractice before it occurs but it is certainly essential to see to it when it has occurred with unfortunate results that those involved are made aware of what they have done and with what consequence.   It is the least we can do to assure that it is less likely the catastrophe be repeated.

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