Argumentative Essay: The Death Of Caroline Carcerano

The death of Caroline Carcerano

Horrific cases of medical errors have become a burning issue in world today. Here’s the case of Caroline Carcerano from Massachusetts .She fell in her Watertown apartment and broke her vertebrae as her bones were fragile due to osteoporosis. She went to Massachusetts General Hospital where the surgeons fused some of her bones. But, she suffered with from surgical pain. Surgeons recommended that she should have a pump stitched under her skin to get analgesics directly to her spine.

The patient went to Tufts medical center in Boston in November 2013 for a procedure to relieve her pain in her back. Dr Steven Hwang, who was the neurosurgeon requested for “Omnipaque”. It is a special dye to test the location of the tube that had been inserted in her spine. The pharmacist didn’t have it. He informed the nurse and gave her a dye known as “MD76”. Dr. Hwang checked the label, and then injected it, twice.

After the surgery, the neurosurgeon said that the pump should work well. However, the nurse reported that Caroline was waking up from the procedure suffering from pain and seizures.

It took twenty four hours to figure out that Carcerano had received the wrong dye. The

neurosurgeon who injected the dye immediately admitted his mistake, saying, “We gave her the wrong dye.” (Kowalczyk, 2014).
As per this case, the physician, nurse and pharmacist or the whole organization was responsible for error. Negligence was the first and the main cause behind this blunder because no one verified the dye before injecting (Kowalczyk, L, 2014). It was clearly mentioned on the label of MD’76 dye that it should not to be used, intra-thecal. Cognitive bias was the second reason. It is also referred as confirmation bias and occurs when a practitioner reads what he expects, rather than what actually is written. It leads to negligence (the clinical advisor , 2014). However, an inadequate communication between the physician, nurse and the pharmacist could also be considered as one of the cause because the physician did not pay attention to the instructions given by nurse carefully that caused Caroline’s death (By Pamela Anderson, 2010).
In addition, working on long duty shifts, interrupted sleep, stress and more work load did not allow healthcare workers to concentrate on their work, which may be the main factors of medical errors. Inappropriate pre-operative management by nurses is also one of the causes (By Pamela Anderson, 2010) because it’s their responsibility to arrange all the medicines and equipments prior to the surgery. Besides this, there is some more common reason that causes medical errors. For instance, medicine unavailability, inaccurate dose calculation, incomplete documentation inadequately trained health care personals, inappropriate abbreviation used in prescription and so on (Medication Misadventures–Guidelines ).
Caroline died the next day after the injection provided to her spine.

After the death of Caroline, the neurosurgeon, Dr Steven Hwang told her two sons that we apologize for our mistake, since we used a wrong dye. Eight months after she died, the attorneys of Tufts hospital send the letters to her sons stating that the surgeon, pharmacists and the nurses were not responsible for her death. Her sons Michael and Steven were totally shocked by reading those letters. They filled a case in the Supreme Court against the neurosurgeon Dr Hwang, 12 pharmacists, nurses and the hospital. William Thompson in Boston who is representing that family told that the insurance company gave a settlement offer after they inquired about Caroline’s case in

detail.
The executives of Dr Hwang and the administrative of the Tufts told that they could not give any opinion since the final decision of this case is still pending. But the hospital had to maintain their reputation, so they made a comment in their favor. They told that the hospital always had good and positive relations with the patients and their families and they are maintaining their policies from a long time. Tufts Medical hospital tried to change their medical treatments. They made lots of improvements regarding the hospital. They strictly told the surgeons and the nurses to make written prescription orders to the pharmacists. (kowalczyk, 2014)
Improving the system to prevent similar future mistakes is essential and actions should be taken immediately. Education is the most important thing to start with. Courses should be offered on the importance of giving the right medications, whether intra operatively, inpatient treatment or from the pharmacy. There are consequences of giving a wrong medication and the side effects to the patients, and that medications in general can be dangerous so we should be very careful in using them.
Any medications that are delivered to the pharmacy or store or any other place where medications are kept should be checked for the name, manufacturing company, expiration date and other FDA criteria for medication labeling. Medication orders or prescriptions to the pharmacy should be written or printed in a very clear way to eliminate any misleading information. Pharmacists in turn, before giving any prescription should make sure the medication and expiration date is correct and if any concerns arise, the pharmacist is advised to contact the prescriber. (American Society of Health-System Pharmacists, 2015)
The Institute for safe medication Practice (ISMP) has 10 elements for effective medication use: patient’s information, drug information, communication, drug packaging and labeling, medication storage and distribution, drug device acquisition, environmental factors, staff education, patient education and quality process. (Anderson, 2010)
In the operation room the nurse should also check the medications in their checklist, making sure it is the right item, right dose, right way of administration, and whether the patient has any allergy before giving it to the patient. Surgeons should also check all medications to make sure that they are correct.
Prevention also includes reducing sleep deprivation of medical staff. It should be insured that the surgeons, assistants, nurses, pharmacists and other staff members have enough breaks and rest times. These factors have a huge impact on decreasing those preventable errors and avoiding unnecessary legal issues.
Preventing medical errors stands out to speak for change in medication safety. This story is an example of a “single – point failure”, happening due to an irreversible point. In addition, it can also be a system misstep instead of a mistake by a clinician. Moreover, it’s hard to make solutions regarding such permanent mistakes made by any individual of the health care system, which affects patients and their relatives ‘emotional, economical and mental status to overcome it. For example, in an airplane, if irreversible decision making is to occur, it requires dual verification to work further on it.
Unfortunately, this incident caused many new laws and regulations to be followed by all respective members of medical centers. This is how it should be, with proper procedures strictly carried out by all health professionals. Following, the Carcerano’s death at Tufts Medical Centre, several other organizations like Massachusetts hospitals started to work on pilot program and passed laws to avoid such medical blunders. As ISO 9000 quality “lingo” states, ‘what you do and do what you say’. Furthermore, it not a bad idea to ‘train the individuals to work and make them to work them as they are trained’. Specific shield and evaluating systems should be applied along with rules and regulations at every medical center. It is widely accepted that medical errors are a prime issue occurring at every health center. But, it’s time to fix such happenings to avoid any grievous effects onto community and countries, to manage their health care systems. Finally, we need to prepare health care staffs to be perfect and well trained with respective trainings and experiences.