MGH faces suit over drug error that killed woman

By Milton J. Valencia Globe Staff, The Boston Globe, March 10, 2011

(See related lawyer’s trial report:
MGH Medication Error Lawsuit Settles for $1.25 Million)

It was supposed to be a routine hospital stay. Geraldine Oswald had developed an infection after breaking her shoulder last year, and she was hospitalized in November at Massachusetts General (MGH) for treatment.

But in a tragic mix-up, hospital staff gave the 76-year-old woman far too much of a blood thinning drug, making it impossible for her blood to clot when she began bleeding internally. Hospital officials later acknowledged the mistake and said it could have been prevented.

According to her death certificate, Oswald hemorrhaged for 12 hours while in the hospital’s care before she died.

Family members said they plan to file a lawsuit in Suffolk Superior Court today naming five doctors, two nurses, and Massachusetts General Hospital in the wrongful death of Oswald, saying the Revere woman was supposed to be treated for a common infection, but instead, a nurse gave her a dose of the blood thinner, called Lepirudin, that was 30 times too high.

“My mother didn’t have to die,’’ said Donna Beatrice. “She could have gotten better. It was this drug they overdosed her with that took her life.’’

A spokeswoman for Massachusetts General Hospital said in a statement yesterday that the hospital regrets the error, and “our hearts go out to Mrs. Oswald’s family.’’

Spokeswoman Peggy Slasman said that the hospital has enacted new guidelines for the administering of Lepirudin. One plan, according to a hospital report, is to improve the way doctors review and approve new dose infusions.

“As soon as we understood what had happened, we apologized and explained the situation to Mrs. Oswald’s family,’’ said Slasman. “We undertook a thorough and extensive internal review of the case, and we communicated with family members throughout this process. As a result of this event, we have made some specific changes to our practices to reduce the chance of such an event from occurring again.’’

The hospital also sent a full report of the matter to the state Department of Public Health. Julia Hurley, a spokeswoman for that agency, said yesterday that the hospital has already enacted new guidelines, so no corrective order was issued.

She also said that, based on the hospital’s report, the state Board of Nursing is investigating the role of nursing in Oswald’s death. However, according to state officials, the two nurses and five doctors do not have a history of complaints or discipline with the state.

According to the lawsuit and hospital records provided to the family, Oswald had been relatively healthy until she broke her shoulder one night last September when she fell while getting out of bed.

She was treated for control of her pain and was put in a sling. While undergoing rehabilitation, she developed a minor urinary tract infection and was admitted to the hospital on Nov. 18.

Her medical records show that doctors decided to give her the blood thinner to prevent the formation of potentially dangerous blood clots while she was hospitalized. But a nurse miscalculated the intravenous dose of the drug, and no doctor provided oversight, resulting in the overdose.

For a day, according to the lawsuit, Oswald lay in her bed overdosing from the drug. By the end, she was bruising and started bleeding from orifices throughout her body. She became unresponsive. By the time doctors realized the severity of her condition, it was too late.

“We couldn’t believe it got to that,’’ said Donald Oswald, her only son. “She was in so much pain. That’s what angers me, to see her go out like that. From a broken shoulder to this, we tried to make sense of it all.’’

Family members requested a meeting with hospital officials. Two weeks after the death, officials told the family that Geraldine Oswald died as a result of a preventable medical error.

According to a report the hospital provided to the family, “the day nurse understood the intended dosing but made an error when entering the dose into the IV pump.’’

The report added, “This excessive medication dose was preventable and a result of a failure of systems within the hospital’s control.’’

Andrew C. Meyer Jr., an attorney for the Oswald family, said yesterday that he was hopeful that the hospital has instituted the changes, but he has no evidence of it.

“As the claim proceeds through the system, one of our goals will be to ensure that these changes for the protection of patients will be enacted and adhered to,’’ said Meyer, a partner at Lubin & Meyer PC of Boston.

“Policy changes won’t bring Geraldine Oswald back home in time for Sunday dinner with her beloved family,’’ he added.

Prescription dose errors have long been the single leading cause of fatal medication mistakes, according to numerous studies. In 1994, Boston Globe health columnist Betsy Lehman died as a result of a chemotherapy drug overdose at Dana-Farber Cancer Institute, sparking a nationwide movement toward preventing such basic mistakes.

Lehman was 39, and her husband, Robert Distel, dedicated part of an undisclosed settlement from a lawsuit against the hospital toward research for breast cancer.

Oswald’s three children say their mother, at 76, was still very active, a bustling woman who cooked and ran errands.

A widow since her husband’s death in 1978, Oswald was still working in Revere City Hall and living on her own. While at Mass. General, she wanted to go home, her family said, and was preparing to do so.

Said her eldest daughter, Ellen Beatrice, “This wasn’t a person who was ready to leave, she wasn’t ready to leave at all.’’

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