Board penalizes nurses
A year ago, Kathleen Shinn blamed Summerlin Hospital's staff for the death of her premature daughter Alyssa.
Today the Southern Hills Hospital registered nurse doesn't feel it's productive to point fingers at any one action or person when the nation's entire health care industry is failing patients.
"The day my daughter died, everyone thought they were doing their jobs. The nurses assumed the pharmacists had done their jobs,'' Shinn told the Nevada State Board of Nursing during its regularly scheduled meeting Thursday. "Our health care industry is full of assumptions.''
Shinn asked the nursing board to help prevent medical errors by ensuring nurses are focused on keeping patients safe and that they are held accountable when they don't.
Her comments, made during the public comment portion of the hearing, came two days after learning that two Neonatal Intensive Care Unit nurses responsible for Alyssa's care had admitted that they did not notice the preemie's intravenous nutrition bag contained 1,000 times more zinc than was prescribed by her neonatologist.
As a result, nurses Jennifer Kailiuli and Lupe Kim are being asked to complete 30 hours of an online course on legal ethics and the Nevada Nurse Practice Act within six months. Also, they will receive a public reprimand, which includes publication of their actions in the nursing board's newsletter.
Their discipline will be in their professional records permanently, according to plea agreements they signed March 13.
Shinn said she wasn't too surprised with the discipline that was taken, although she said a suspension or, at the very least, probation would have made her feel a little better.
"I knew they would, at a minimum, plead guilty to unprofessional conduct. You can't defend that,'' she said. "They did not check the label.''
Alyssa was born premature Oct. 19, 2006, at 26 weeks.
She weighed 1 pound, 4 ounces.
She died on Nov. 9. A coroner's report said Alyssa died from cardiac failure caused by zinc intoxication and zinc overdose. The report listed "extreme prematurity" as a significant condition of the infant at the time of death.
The mistakes that led up to Alyssa's death started the night before when a pharmacist mishandled the entry of her prescription into the pharmacy's computer. It ended with the neonatal intensive care nurses hanging the IV bag.
For failing to verify the accuracy of the order, the Pharmacy Board fined two pharmacists $2,500 and ordered them to attend its continuing education program.
Pharmacists Nazanin Rezvan and Jackson Yu had their licenses suspended for 30 days. Yu was also ordered to complete 10 hours of continuing education on medication errors.
Pamela Goff, the pharmacist who admitted to entering the wrong amount of zinc on the order had her license suspended for 30 days. The suspension, however, was stayed because her employment at Summerlin Hospital was terminated.
Asia Cornelius, the pharmacy technician who filled the order, putting the zinc in Alyssa's total parenteral nutrition bag, received no punishment.
Summerlin Hospital's pharmacy was ordered to pay the maximum fine of $10,000, plus fees associated with the Pharmacy Board's hearing and investigation.
During a day-long Pharmacy Board meeting in July, Goff tearfully admitted to the data-entry mistake, but also described unsafe practices at the hospital, which included prescriptions arriving in the pharmacy late.
She also said physicians were consistently writing prescriptions in a manner in which she disapproved.
Since the Pharmacy Board's hearing, Summerlin Hospital has implemented several policy and practice changes to prevent pharmaceutical errors from occurring again, hospital officials have said.
Shinn, director of Southern Hills Hospital's medical surgical telemetry unit, travels the country speaking about medical errors in hospitals. She also holds seminars in Nevada and trains nurses.
Her mission is to protect patients and teach others to do the same.
Referring to a Institute of Medicine report released in 2006, Shinn said more than 100,000 people die each year due to medical errors in the United States. Most of these deaths could have been prevented, she said.
Shinn said Nevada's hepatitis C crisis should be a wake-up call to medical care professionals about how medical mistakes can harm patients. For her part, Shinn is encouraging nurses at Southern Hills Hospital to bring unopened syringes into exam rooms and open them in front of patients.
"We have a lot of work to do to build that trust,'' said Shinn. "Patients are defensive right now and they have every right to be because they're frightened. We're all frightened.''
Contact reporter Annette Wells at awells@reviewjournal.com or 702-383-0283.
