Posted on Wed,
Nov. 02, 2005 at:
Medical mistake may
have killed man By Julie Sevrens Lyons
A 21-year-old San Jose man underwent chemotherapy in August hoping
it might cure his lymphoma. Instead, it may have killed him -- as human
error at Kaiser Permanente's Santa Teresa Medical Center led to the man
being injected with the wrong medication, state investigators have
Christopher Robin Wibeto's cause of death is still
by the county coroner's office. But state officials have determined
the San Jose man was wrongly given another patient's medication, a
drug called vincristine.
In Wibeto's case, it appears that chemotherapy
medication meant for
another patient was mistakenly delivered to his bedside, and doctors
nurses didn't notice it was the wrong drug until after they had already
administered it, said Norma Arceo, a spokeswoman for the state
of Health Services.
``It was a human error, unfortunately,'' she said.
Wibeto's doctor, whose name has not been released
by state investigators,
injected the drug into his spine, thinking it was another medication
can safely be administered that way, according to the state report.
Vincristine is usually fatal when injected into
the spine -- in fact,
a hospital safety organization issued a nationwide warning to hospitals
about this danger in July -- the month before Wibeto's Aug. 29 death.
``Despite repeated warnings over the years and
extensive labeling requirements
and standards, tragic errors related to the inadvertent administration
of vincristine'' into the spine ``continue to occur,'' the Joint
on Accreditation of Healthcare Organizations cautioned. ``And, while
events occur infrequently, such `wrong route' errors are very
Indeed, state investigators have found the Kaiser
hospital did not follow
proper protocol in giving the medication without having the doctor and
nurse first confirm it was the right drug for the patient.
The hospital is being cited by the state for its
breach, and the case
has been sent to the state attorney general for review, Arceo said. A
for the attorney general's office did not know Tuesday whether a
investigation into the matter is under way. Hospitals, unlike nursing
are not fined when there are ``deficiencies'' in their care, Arceo
``We have expressed our deepest sympathy and
regret to the family and
wish to reiterate those sentiments now,'' said Kaiser spokesman Rick
in a written statement. ``We are sorry for this tragic occurrence.''
Malaspina said that the hospital has cooperated
with state regulators,
initially reporting the accident, and is doing everything it can to
such a mistake never happens again.
``We are committed to assuring that the
circumstances which led to this
tragedy are not repeated,'' he said. Malaspina did not say whether any
workers were fired or suspended, and did not provide any details on the
changes the hospital has made.
Medical mistakes are relatively common at
hospitals throughout the country,
although most aren't fatal.
Still, a sweeping report by the national Institute
of Medicine in 1999
estimated that medical errors in hospitals kill between 44,000 and
Americans each year. Last year, a patient at San Mateo Medical Center
after allegedly being given 10 times the prescribed dosage of
``These errors, for the most part, are not because
of carelessness on
the part of caregivers, but because the systems they utilize to provide
the care have not been carefully examined and redesigned to make them
for patients,'' said Dr. Lonnie R. Bristow, a former president of the
Medical Association, who helped write that report.
Bristow, who lives in Walnut Creek, believes such
mistakes are less
common now. Medication mistakes account for about 20 percent of the
that occur in hospitals, sometimes because of things like poor
Wibeto, a San Jose native, died three days after
the medication error.
His family could not be reached Tuesday.
Contact Julie Sevrens Lyons at firstname.lastname@example.org
or (408) 920-5989.
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