Never-ending impact
Posted June 8, 2023
The three nurses who clocked in for their shifts on the fourth floor of Samaritan Hospital in Troy, N. Y. one evening back in November 2003 could not have imagined that the collapse of one of their patients that night would set off a series of events that is still going on 20 years later.
The patient, who had try 1 diabetes, was Lisa Baker. Just after 2 a.m. on November 11 she was found not breathing and - according to an entry in her medical chart - with a blood/glucose level of 2 mg/dL.
Any reading below 60 mg/dL requires immediate treatment.
Lisa lapsed into a coma, her brain and other organs damaged by the lack of glucose and oxygen. She died three weeks later.
The medical chart shows no indication that a check of her was done for the four hours after a first episode of hypoglycemia earlier in the evening - even though checking to ensure that a patient’s glucose has stabilize at a safe level is required by the hospital’s “hypoglycemia protocol”, a written instruction the attending physician had that evening ordered in a written entry in the chart to be used if Lisa’a glucose level dropped.
That collapse, and the hospital’s refusal to acknowledge what its own records show, led to two lawsuits, one against the hospital and two doctors, the other, naming four individual staff members that was filed after the hospital refused to allow the first complaint to be amended.
The claims were dismissed after Samaritan Hospital’s lawyers paid Mathew Leinung, an endocrinologist at Albany Medical Center, to provide an affidavit saying that the nurses who ignored the attending physician’s written order did not fall below the standard of care. This despite the medical chart showing that what happened - hypoglycemia that starts while a patient is a healthcare facility - was what Medicare later termed one of 28 ’never events’ events so egregious that they should never happen, and for which it would deny payment for treatment resulting from the event, and that Lisa’s death certificate listed as a cause of death “profound hypoglycemia,”
But that rule was not in effect in 2003; Samaritan Hospital was paid $73,000 for treating Lisa in its ICU for the three weeks she was in a coma prior to her death.
The dismissal of the lawsuit prompted this blog, with its details of dozens of lawsuits against Capital District hospitals alleging deaths and serious injuries, lawsuits that the area’s media had ignored, while running endless ads for the hospitals.
A related web page brought a lawsuit in 2012 from the hospital; an obvious attempt to suppress information about the lawsuits. The lawsuit was resolved after two years with a change of its web address. It is still up, with the new address, capitaldistrictheslthclaims.com.
And now a book about Lisa’s case is coming, creating a near permanent record of the events surrounding Lisa’s totally preventable death.
—
Four people are listed in the hospital records - and were named in the second lawsuit - as being on duty in the hospital’s fourth-floor Progressive Care Unit that night. Of those, it was Mary Ann Salvana Lee, then 33 years old, who signed the chart entries relating to Lisa.
Lee had been issued a New York nursing license just nine months earlier, on February 21, 2003, according to the state’s online listing of professional licenses. It is still current, expiring on January 31, 2026. Lee, now 51 years old, is still living in the Albany area.
Of the other three, Mary Kay Keller and Mary Martin have either retired or left the profession; their licenses have expired. There is no indication that the fourth person listed in the hospital’s records, Elza Villajuan, has ever held a nursing license; either her name was misspelled or she may have been a patient aide.
—
There are many ways people can unintentionally cause serious injury or death: Leaving a child to die in a hot car; Not securing a gun that is then found by a child who unintentionally shoots someone.
Or giving a patient an IV shot into her spine instead of a vein, as two doctors at Albany Medical Center Hospital did in 1985, taking the life of 21-year-old Lillian Cedeno and her unborn child.
And most people who make such a mistake will live with it for the rest of their life, reliving over and over the details of the event.
Some seek relief from the guilt with alcohol. Marriages will be destroyed. Some people take their own lives.
Others go into denial, refusing to admit even to themselves that they are responsible for the tragedy.
The first victim is the patient harmed or killed by a medical error.
The others are first the patient’s family - and then the people who made the error, and might want to acknowledge the mistake but are left to suffer in silence by management’s routine aggressive defense of every claim that it was responsible for an injury or death in its facilities.
**********
Link
How a terrible mistake by two Albany Med doctors took two lives: https://bit.ly/3NkpgzS
**********************
posted by David @ 7:34 PM
<< Home