In a span of only a few hours, nurses at a Florida hospital operated by the giant Tenet Healthcare Corporation mistakenly gave two pregnant women a drug commonly used to force dead fetuses out of the womb. One woman lost two unborn twins and the second gave premature birth to a daughter who suffered severe brain damage.
One of the women is now suing Tenet in cases that safety advocates say underscore the continuing problem of prescription errors that should and could old be easily caught.
"These two women were supposed to be safe, on bed rest, and the worst possible thing happened to them," said David Kelly, an attorney representing Tesome Sampson, and her 11-month old daughter Traniya, who suffered brain damage and remains hospitalized due to health complications.
Sampson was five-and-a-half months pregnant when her doctor ordered her to strict bed rest at St. Mary's Medical Center in West Palm Beach last August.
But instead of giving her the progesterone suppositories the doctor had ordered to prevent premature labor, the hospital staff mistakenly gave her a dosage of Prostin, a powerful drug used to induce labor and expel fetuses out of the womb after miscarriages, according to a complaint filed in a Florida court.
After four hours of extreme abdominal pain and cramping, Sampson gave birth to Traniya, expelling her in a commode after nurses said she just "needed to have a bowel movement."
Kelly says that incident involving the twins, which happened just hours earlier, should have made the hospital staff more cautious in administering the medication, but instead they missed numerous opportunities to catch the error.
St. Mary's Medical Center, which is operated by hospital giant Tenet Healthcare, apologized to the Sampson family in a statement release yesterday and acknowledged the mistake. The hospital described the incidents as "an unfortunate error that occurred despite the safeguards we have in place."
A hospital spokesman did not respond to questions about the incident involving the twins. However, the hospital issued a very similar statement and apology last year, according to local news reports.
What Can Go Wrong
Medication safety advocates say such serious yet avoidable errors continue to occur, despite a decade-long effort to improve hospital systems.
"There really are so many things that can go wrong -- so many procedures, processes, changes in personnel," said Michael Cohen of the Institute for Safe Medication Practices, a Pennsylvania-based non-profit group dedicated to medication error prevention.
Studies estimate that 400,000 preventable drug-related injuries occur every year, according to a 2006 by the National Academies' Institute of Medicine.
Often, the mistake originates with a doctor's scribbled handwriting, which appears to have been a contributing factor in the Sampson case. Part of the problem, says Cohen, is that only 10 to 12% of hospitals have computerized systems that can be used by doctors.
Look-alike and sound-alike drugs are also a source of concern. For example, Cohen's group has compiled a list of more than a thousand commonly confused drugs.
Cohen says that when tragic errors like the ones at St. Mary's occur, hospitals have a responsibility to work with federally certified patient safety organizations to conduct a top-to-bottom review of hospital procedures and systems to ensure such errors never happen again.
"There are a lot things that can be done to disallow that type of error, and the thousands of other errors that we've seen in the last 15 to 20 years, from happening," he said.
The hospital said in its statement that it had reported the incident to authorities and "took the necessary steps to prevent something like this from happening again."
A hospital spokesperson did not respond to questions asking for details on those measures, or the previous incident involving the loss of the twins.