The Perils and Dangers of Hospital Care

On May 26, 2006, a woman who was 7 months pregnant died in South Florida Baptist Hospital because a nurse gave her an overdose of magnesium sulfate. The doctor ordered 4 grams to stop early labor pains, but the nurse accidentaly administered 16 grams. The woman immediately began having trouble breathing.

"I knew something wasn't right," said her husband. "I tried to tell them, and they wouldn't listen."

Once the mistake was realized, doctors tried to save her by any means possible including giving calcium to counter the effects of the overdose. She checked into the hospital at noon and was dead by 3 PM. It was unclear how long it took to detect and begin treating the overdose. Perhaps if they had paid more attention to their patient and taken note of the changes in her breathing pattern or if they had simply listened to the pleas, trusted the instinct of the man who knew her best and had tied his life to hers, her life would have been spared.

According to her husband, "Within 10 minutes, everything was wrong." What a difference ten minutes can make. What a difference it could have made had more attention been paid to this patient and her husband.

The couple's son was delivered by emergency C-section and went straight to the neonatal intensive care unit. He was having some breathing problems at first but managed to survive, though he will inevitably face many more challenges due to his premature birth. He and his two year-old sister must now grow up without their mother, who at one point during her father's interview stretched out her arms and cried "Mommy!" At the time she still didn't know about her mother's death as nobody quite knew how to tell her.

As of June the nurse was on administrative leave for the remainder of the investigation and was expected to return to her job. She had been considered an 'outstanding team member' by the hospital where she had worked for 7 years. Hospital policy now requires extra supervision when administering magnesium sulfate, and changes to the computer system have been made. It is sad that they waited for an event like this to occur before doing what they should have been all along: paying attention and being careful. Such care should be used when giving any medication and when treating any patient.

Bill Ulbricht, the hospital's chief operating officer, had this to say "We want our community assured this was a one-time incident. This is a good place to come for health care."

This family once believed that. The two year-old little girl was born at this hospital. "We had too much faith in them," said her father, now a widower at only 21. This sad story is just evidence of the dangers of blind faith in the medical system and proof that mistakes can and do occur even in hospitals under the supervision of nurses with 20 years of experience. The medical system could really take a lesson from the midwifery model of care, where patient and instinct come first, where careful attention is paid, where a bond is formed between caregiver and client.

Perhaps if those conditions had been met, the life of this woman would have been spared. A child would have been born at term, not prematurely. Two children would have grown to know their mother, rather than losing her before they even hit grade school. A young woman would have been able to live out her life with her family. A young man would not have become a widower and single father before he was even old enough to rent a vehicle. None of those things would have happened if this hospital had treated this woman as an individual, paid attention to her, heed the warnings of her husband, and paid more attention when administering potentially dangerous drugs.

This was a mistake, but it could have been prevented...and the effects could have been reversed, if only the attitudes of the professionals had been different. No model of care will ever be 100% safe, as all humans can make mistakes. So many of them can be prevented by using caution; so many lives could be saved if more attention was paid. Of all the dangers of the hospital, the most dangerous has to be the attitude of professionals who do not know their patients well enough to sense when they are in peril, who do not trust their clients enough to listen to their concerns, and who do not take the time to adequately supervise their assistants when giving medication (or better yet do it themselves).

Lisa Greene, "Hospital says error killed woman." St Petersburg Times. URL: (http://www.sptimes.com/2006/06/07/Tampabay/Hospital_says_error_k.shtml)