Beijing Tiantan Hospital Administered Wrong IV Drip, Patient Passed Away
September 3 report: Beijing, August 31, a patient named Wang Huali, a man from Henan who was undergoing intravenous infusion treatment at Tiantan hospital, had a sudden [adverse] reaction when receiving the third bottle of IV drip, and his family was informed that the hospital was unable to rescue him. According to the family members, after handling transfer procedures, they rented a car to take Wang Huali back to his hometown, but while on the way, they discovered that on the drip bottle still hanging on Wang’s body was marked with another patient’s name. They immediately took the dead body back to the hospital to seek an explanation. A representative of Tiantan Hospital Medical Affairs Office admitted to the family members that the third drip used on the patient was a mistake on the part of a nurse at the hospital, but whether the cause of death was caused by the misapplication of medication [in the IV] still needed investigation. [September] 2, a relevant Tiantan Hospital representative claimed that the hospital had begun a self-investigation, and will punish the person responsible on the basis of the results of the investigation and relevant regulations. At present, the hospital and the family members of the deceased are negotiating on the matter of compensation.
2013 September 1, the head nurse of the ward where the incident happened and the attending doctor of the deceased confirming the drip bottle and acknowledging that the wrong medication had been administered.
According to Wang Huali’s eldest daughter Wang Yun (pseudonym), her father was from Henan Shangqiu, and was 65 years of age. This July 30, he was diagnosed with benign craniopharyngioma. August 19, he had an operation in Tiantan Hospital. “12 days after the operation, my hospitalized father was recovering well.” According to Wang Yun, August 31, he received intravenous infusion therapy as usual. From 8am to around 9:40am. Two bottles of medicine had been infused, and the nurse began changing to the third bottle of medicine.
“Less than 5 minutes after beginning the infusion (of the third bottle of medicine), I discovered my dad’s right hand turning purple and hurriedly called the doctor.” Wang Yun said that the doctor immediately began emergency rescue efforts. “But soon they told us that because of pulmonary embolism, the patient was unable to be saved.” Picture is of 2013 September 1, the misused medicine bottle (the left bottle).
According to Wang Yun, at around 11 am that day [August 31], they rented a car to take [the body of] her father back home. When the car was approaching Baoding, her younger brother by accident discovered that the infusion bottle hanging on his father’s body was labeled with another person’s name: Jiang X. Then the family members took the body back to Tiantan Hospital. [September] 1, at around 3:30pm, on spot No.24 of the Tiantan Hospital morgue, a needle was still inserted into the left thumb of Wang Huali’s body. Two bottles of medicine solution were placed side by side by the lower part of the body. One was labeled glucose injection, and another one was labeled “Bed Number: 26, Name: Jiang X (male)”, with about one-fifth of the liquid remaining. The medicine bottle labeled with “Bed Number: 26” shows that its ingredients included “5% 500ml glucose and sodium chloride injection”, “40mg omeprazole sodium for injection”, “1.5g: 10ml (plastic) potassium chloride injection liquid “,” 10ml: 400iu insulin injection liquid 4iu “. According to Wang Yun, when her father was in the hospital, his bed number was 22. Picture is of 2013 September 1, the misused medicine bottle label not matching the name of the deceased.
[September] 1, the head nurse of the ward in which the incident happened and the attending doctor of Tiantan Hospital verified the infusion equipment, the solution, the needle tubing marks, etc. that were still inserted in the left hand of the body of Wang Huali. The head nurse admitted that the infusion equipment, the medicine solution, and the needle tubing the deceased still carried were indeed a mistake by a nurse of their ward. By checking the medication records of that day, it was confirmed that the first two infusion bottles were not incorrect, and only the third one was incorrect. [September] 1, a person in charge at the medical department of Tiantan Hospital surnamed Guo apologized to the family for the hospital’s mistaken misuse of medication. However, she expressed that whether the patient died due to the mistaken medication or not still needed to further determination by the relevant departments. [September] 2, according to a relevant person in charge at the Advocacy Center of Tiantan Hospital, the hospital was resolving the incident through consultation with the family members of the deceased, and an investigation was launched at the same time. The relevant people who are responsible would be punished according to the investigation results and the details were not convenient to be disclosed. According to a relevant person in charge at the Beijing Municipal Health Bureau, [they] were aware of this incident but currently [this incident] is being handled mainly by Tiantan Hospital in consultation with the family members of the deceased and could not comment on the incident. Picture is of the misused bottle label not matching the name of the deceased.
“I remember the nurse she didn’t scan the bar code at all when changing the medication [IV bottle],” recalled daughter Wang Yun, who had been at the scene the entire time, of the nurse’s inappropriate handling after Wang Huali had a reaction. In response to the suspicions by the family of the deceased, the head nurse involved responded that among the hospital’s nurses’ daily operating procedures, [they] would fulfill the “3 inspections and 7 verifications” system, carefully checking bed numbers, the names, the names on the medicine, the dosage of each medicine, the time, the concentrations, and the methods. According to the head nurse involved, if the above operating procedures are followed, it is impossible for there to be mistakes, and since there was a mistake with the medicine used that day, the nurse on duty may have made a mistake during medicine procedure, but which specific step went wrong needed further investigation.
Regarding the reason for the patient’s death, the patient’s family members believe that it was caused by the nurse’s administering the wrong medication. “The infusion of the third bottle had only gone on for only less than 5 minutes when [the reaction] happened. It was obviously the effect of the medicine.” According to Wang Yun, after her father’s surgery, the doctor repeatedly warned her not to give her father foods with high sodium, while the medicine that day that her father was wrongly infused with, both the “5% 500ml glucose and sodium chloride injection” and the “40mg omeprazole sodium for injection” contained sodium. According to Wu X, attending doctor of the deceased, the patient died of pulmonary embolism, “only pulmonary embolism can cause the death of a patient in such a short period of time.” He also admitted that when the patient came for treatment, his sodium was indeed high, but he believed that even if the patient had high sodium, to infuse “5% 500ml glucose and sodium chloride injection” would not lead to pulmonary embolism. As for the cause of the pulmonary embolism, he believes it was poor blood circulation due prolonged bed rest following major surgery that led to pulmonary embolism. The specific reason can only be determined through an autopsy.
According to a Beijing Times report: Wang Huali “died following unsuccessful attempts to save his life”. Afterward, the family members wanted to follow the custom of his hometown, to “bury him in peace”, did not agree to a cremation and without getting a death certificate, they rented a car transporting the body out of the hospital. According to a doctor surnamed Lv who participated in the efforts to save the patient, the condition of the patient at the time was “couldn’t be saved, though the ventilator was still on”, but the patient hadn’t been declared clinically dead when he was taken from the hospital. “Unable to be rescued and clinical death are two concepts.” “If his clinical death was declared, he could not be taken, and he would be taken to the morgue, so letting you take [the body] away then would be illegal.” In a video of negotiations provided by the family of the deceased, Dr. Lv rebuked. Wang Yun claims the family members ultimately conducted a critical hospital transfer procedure with the hospital. Picture is of 2013 September 1, the ward where the incident happened banning outsiders from entering.
Comments from NetEase:
I recommend having this kind of nurse transferred to the cadre [government officials] ward.
党说国外都水深火热 [网易湖北省武汉市网友]： (responding to above)
On behalf of only myself, I completely support that.
To be honest, major hospitals are very chaotic when there are a lot of people getting IVs, and the [nurses] there are all interns from all kinds of nursing schools, very clumsy! Although getting an IV is a small thing, it can be a really a big problem if the wrong medicine is infused. When brother [referring to himself] gets an IV, I always check the name carefully, never go to sleep, and watch the changing of the IVs… It really is too chaotic when there are a lot of people getting IVs~~~ And the little nurses don’t have a strong sense of responsibility~
Getting the wrong IV means two people got the wrong IVs!!! How is the other person???
It shouldn’t be like this. Even if a big hospital has too many things to do and [doctors and nurses] are too tired, but when it comes to people’s bodies, they should always maintain vigilance. Whether the death is caused by the medicine or not, the fact remains that the wrong medicine was changed and the nurse involved should be held responsible.
网易河北省石家庄市网友 : (responding to above)
The nurse, don’t you feel wronged? Think about it, if she was a new intern, she doesn’t get paid but must still work hard as a nurse. In the hospital, they have to put up with the leadership/management, and they dare not leave work early, only able to leave later than others. I know a nurse where it was just like this. In the beginning the hospital didn’t pay her, later on they paid her 800 yuan [per month], and after a while, she just quit entirely.
网易辽宁省鞍山市网友 [名字让人取了]: (responding to above)
She should have been prepared for this after she graduated and chose nursing. Every job’s responsibility is different. You can’t complain just because you feel you’re working hard and are getting paid little, nor can that ever be an excuse for negligence/malpractice! Such a person would be doing everybody a favor by just quitting.
网易江苏省盐城市网友 [wbxsabcd]: (responding to above)
A nurse’s salary is very low. Don’t say “such a person would be doing everybody a favor by just quitting.” Salary determines the staff, so there won’t be very excellent nurses providing you service [when they are paid little].
网易辽宁省网友 [吉尔瓦伦丁]: (responding to above)
This is a job involving life and death. If you [feel] the salary you make is low, you can just not do it [quit], because your faults may result in other people losing their lives.
网易重庆市网友 [维修掏耳勺]: (responding to above)
Truly really ridiculous. So a ls low salary or no salary is a reason for changing the wrong medicine? You don’t have any salary or have a low salary now so that you can have a high salary in the future! I suggest severe punishment [for the nurse involved]!
网易广东省深圳市手机网友 [元亨利贞]: (responding to above)
Stop working as a nurse if you don’t think you are cut out for this job or if you think the salary is low… But since you have taken this job… be responsible… A little bit of error may lead to a person’s death… I don’t think I could do this job.
Who knows, maybe it’s a temporary worker yet again.