Lisa Zenzen Baker, 1961-2003


Sunday, May 15, 2011

IV not flushed

Health Department cites hospital
in blood-thinner overdose death

By David Baker
Posted Sunday May 15, 2011

An anesthesiologist and then, an hour later, a nurse at Samaritan Hospital failed to flush out an IV, causing a patient to twice receive a large dose of the blood thinner heparin, according to documents obtained from the Department of Health under the state’s Freedom of Information Law.

The patient, Joseph Bartoski, died the next day. As was first reported here in July 2010, a lawsuit filed by his widow, Dorothy, is pending in state Supreme Court.

This, according to the Health Department’s findings, is what happened:

In June of 2009 Bartoski, who had end-stage renal disease, underwent surgery at Samaritan Hospital to repair a venitral hernia. While preparing for the surgery, an anesthesiologist determined that an IV needle that has been placed into the patient’s hand was not acceptable and decided to administer drugs via a dialysis catheter already in place.

However, he failed to flush out a port on the catheter to remove about 10,000 units of the blood thinner heparin which had been placed in the port to prevent blood from clotting in the device.

Flushing out a catheter is required by the hospital’s protocol, which states: “Due to high concentration of Heparin in the catheter lumens, 5 ml must be aspirated and discarded each time a lumen is accessed.”

During the surgery, Bartoski began bleeding from the nose, mouth and the surgery incision.

He was then moved to a recovery room, where a nurse again failed to flush another port on the catheter before administering another fluid, causing Bartoski to receive another 10,000 units of heparin.

Bartoski was given a dose of the drug Protamine in an attempt to reverse the effect of the heparin. However he continued to bleed and a further dose was given.

But the Department found that the effort was insufficient.

“Expert review felt that although Protamine was the drug of choice, the amount given was not adequate and medication was not given in a timely manner,” according to an investigation report.

The nurse is identified as Doreen Fitzgerald. A report of an interview with Fitzgerald says she: “Knew when pt arrived in PACU that he was going bad. Drs present yelling orders. Knew the policy but also knew the patient needed meds or he would die. Doesn’t know why she didn’t aspirate. Has been a nurse 29 yrs. No problems.”

The anesthesiologist was not cited by name in these documents, which deal only with the hospital and its nursing and medical staff. But the lawsuit filed by Bartoski’s widow names as defendants Dr. Ike A. Boka, and Empire Anesthesia Medical Consulting LLP. And in a note in an investigation report, a box is checked that says Boka was directly involved in the patient’s care and that during an interview, “Dr. Boka indicated that he was familiar with hemodialysis caths but was not familiar with the policy to aspirate prior to instilling solutions.”

After the Department completed its investigation, the records and findings were sent to IPRO – the Island Peer Review Organization – with a request for opinions on the care given to Bartoski. One of the questions asked was if an anesthesiologist should have been aware that heparin is placed in a catheter between infusions.

IPRO’s answer is not available to be reported here because its entire response is redacted from the records obtained from the Department. However, in a report of the investigation, a paragraph headed ‘Investigative Summary’ says: “Unanimous opinion was that standard of care was not met. Allegations were substantiated.”

Samaritan Hospital was then ordered to submit a ‘plan of correction,’ which it did in March 2010. But that, too, is redacted in its entirety.

There is no indication in the records provided that a fine or any other penalty was imposed on the hospital.

Meanwhile, Samaritan Hospital and Dr. Boka are continuing to fight the lawsuit, denying any responsibility for Bartoski’s death.

UPDATE: The Bartoski lawsuit was settled on the first day of trial for $350,000.  The case was totally ignored by the area's newspapers.

COMMENT: Ignoring instructions seems routine. Read the editorial HERE