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Originally Posted on Wed, Nov. 02, 2005 at:
http://www.mercurynews.com/mld/mercurynews/living/health/13058936.htm

Medical mistake may have killed man By Julie Sevrens Lyons Mercury News
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 found.

Christopher Robin Wibeto's cause of death is still being investigated by the county coroner's office. But state officials have determined that the San Jose man was wrongly given another patient's medication, a cancer-fighting drug called vincristine.

In Wibeto's case, it appears that chemotherapy medication meant for another patient was mistakenly delivered to his bedside, and doctors and nurses didn't notice it was the wrong drug until after they had already administered it, said Norma Arceo, a spokeswoman for the state Department 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 that 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 Commission on Accreditation of Healthcare Organizations cautioned. ``And, while such events occur infrequently, such `wrong route' errors are very preventable.''

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 spokesman for the attorney general's office did not know Tuesday whether a criminal investigation into the matter is under way. Hospitals, unlike nursing homes, are not fined when there are ``deficiencies'' in their care, Arceo said.

``We have expressed our deepest sympathy and regret to the family and wish to reiterate those sentiments now,'' said Kaiser spokesman Rick Malaspina 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 ensure 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 98,000 Americans each year. Last year, a patient at San Mateo Medical Center died after allegedly being given 10 times the prescribed dosage of chemotherapy medicine.

``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 safer for patients,'' said Dr. Lonnie R. Bristow, a former president of the American 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 errors that occur in hospitals, sometimes because of things like poor handwriting, he said.

Wibeto, a San Jose native, died three days after the medication error. His family could not be reached Tuesday.
Contact Julie Sevrens Lyons at jlyons@mercurynews.com or (408) 920-5989.
 
 

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