Dozens of Mistakes Caused Death of Young Hospital Patient, Court Rules
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- Опубліковано 27 вер 2024
- Documents obtained by NBC Bay Area’s Investigative Unit show medical staff at UCSF nearly quadrupled a young patient’s opioid medication and then failed to monitor him with a pulse oximeter, a simple medical device that would have alerted them if his blood oxygen level fell to a dangerously low level. Jessica Aguirre reports.
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I'm a nurse in Canada
This happens alot more than you would like to think. The only difference with this case is that it got investigated. Many don't.
A cardiologist wanted me to take 5 medications just because the treadmill stress test assistant got me angry and my blood pressure went up . Later I found more of his patients had same experience. Time to tell OHIP fire incompetent doctors. Doctors ,glorified drug pushers all of them
And that’s a fact!!!
So sad
I'm a RN in Canada and I was overdosed during a radiology interventional procedure. They gave me NARCAN. The doctor chuckled, said welcome back we overdosed you, Sorry. I know how it happened because the system is set up for failure. But I couldn't find one person interested in patient safety to take a report in that hospital. Disgusting.
I’ve see a RN lie about one of residence (age care) he passed in the middle of the night 🤦🏻♀️ was only meant to be in respite for a couple of weeks while recovering 🤦🏻♀️🤦🏻♀️ he passed the first night because he was never checked on overnight his room was freezing we were in the middle of winter. I got really pissed off when I saw the RN close his window and turn on heater to warm him and his room. I was a (personal caregiver) when I found him and there was no way in hell they were going to believe me 🤬🤬I’ve seen it more than once
How much of these errors were caused by uderstaffing because hospital admin wants to line their own pockets with money instead of hiring more nurses?
Absolutely on point!!!!
yes!
Also, the insurance companies who are just as bad, if nit worse!
Someone with a lick of sense here!
probably half of them. honestly need to sue more individual nurses. As much as it hurts my heart for the nurses. They need to quit if they cant do the job being placed upon them.
My father had a heart attack last month, had to get a stat procedure done in cath lab where he had a stent placed and thrombectomy for 99% occlusion of one of his coronary arteries. I went to visit him in recovery and he was on NO monitoring and also on a nitroglycerin drip for residual chest pain (which also decreases blood pressure). Luckily I’m an icu RN and when I asked the nurse caring for him why isn’t on monitoring she claimed “oh he doesn’t have to be”. I went straight to the charge nurse with my concerns and requested that they take his vitals and keep him on monitoring until he is in the pcu (he’d been waiting hours for a room and had to wait in recovery). When they took his vitals his blood pressure was already dipping below therapeutic. Imagine that someone has a heart attack and the incompetent thinking of some healthcare staff is that they don’t need any sort of vital sign monitoring (no ekg, no oxygen sats, no bp). And I say this as a nurse, sometimes the critical thinking in some facilities can be pathetic.
that is the problem, there is NO critical thinking for many of them. i have stories for sure, sure you do also. its alarming.
How the fuck was he not monitored when receiving a vasodilators..,..?!!?!???!?!?!?!?! I can't not believe it .. those. Farmaceuticals have to be administered with stric monitorization
Thank goodness you were his advocate! I have had to step in for family members and advocate as well.
Unbelievable. Makes you question what education and clinical training they've had
Horrible.
How horrifying! His poor sister must carry such unwarranted guilt.
What a tragic story. Ugh, can you imagine the guilt his sister feels?!! My brother donated a kidney to me ( University of Maryland in 2016), and I would feel like it was my fault if something had happened to him during his recovery.
I worked for them !!
How are you doing ?
@@Justforme7 Better than ever! 5 years post-op kidney transplant, 3 years post-op pancreas transplant. Univ. of Md. did an amazing job. Thanks for asking! 🥰🙂🙂🙂
@@tinaa2677 I gave my mom a kidney in 2006! Glad you’re doing well! God bless!
@@rjules1083 So grateful for people like you!! ❤️
This is one reason why I'm scared to have any operations . One minute you're good, next my son is an orphan. It's too scary to even contemplate
Hospital staffing has run off most experienced floor nurses that would catch this kind of thing. You can’t make enough policies to replace expert level nurses. Most hospital nurses have 1-3 years only.
And it is NOT just on is Nurses to catch all of these things! We are responsible for so many patients we can’t catch everything!!! We work as a team, everyone is accountable!
That and now more inexperienced nurses are trying to run away from horrible working conditions of bedside and become NPs with little floor or life experience; this is a matter of patient safety but universities and medical organizations only see profit. Imo, a NP is not a doctor substitute. Healthcare field is so messed up; hires NPs as cheap labor and expect them to do same type of work as a doctor. No offense to NPs but I've heard from my clients on multiple occasions NPs prescribed them medications that actually made them worse off based on their other medical conditions. One of my client's son, who is studying to be a nurse, caught one red handed in an outpatient setting and luckily the pharmacist agreed and had to call the doctor office to tell them they're nuts. Even he as a nursing student is now biased and refuses to allow an NP to see his parents. I'm a nurse myself and I do not trust NPs. The training and the licensure is just not the same as an actual doctor.
@@TheTruthHurts6666 yep, bedside is ridiculous, demands for all of the required duties is ridiculous, lack of good techs is ridiculous, everything is ridiculous.
Touche
Yes - there was a brain drain on the hospitals just before Covid hit when they offered early retirement incentive to the experienced nurses that are so vital to patient safety.
As a medical doctor myself I HATE the hospital as a patient and I” paranoidly” go over every patient I see. I’m the doctor who does too much.
When I was having my baby with so much prayers and GOD, my Husband also a doctor with over 10 years of experience (he used to be a paediatric resident but later went on to do family medicine) NEVER left my side. I pray everyday never to be admitted to hospital.
I pray for healing for this family
What does god have to do with anything?
Honestly, hospitals are deadly. I try everything possible to avoid them, but they're unfortunately unavoidable for a lot of us. I'm glad you have a good partner. It makes all the difference
I thought that $2 million wasn’t enough, and then when they decreased it to $250,000… I’m speechless and heartbroken for this family. 💔😞
Remember the lady that got burned by hot coffee at McD’s? She got 3 million
Regarding McDonald's comment @Laura Gwillim The photos of the elderly woman's burns were very horrendous. She should have received more than 3 million. Her quality of life changed and she died within a couple of years I think. There's a documentary about her story.
@@soupnfresh yes, imagine having your genitals disfigured...and the pain, oh God, the pain...
@@lauragwillim1055 No, she didn’t. The jury awarded her $2.7 in punitive damages, but the judge decreased it to $480,000, an amount that wouldn’t have been very punitive to a huge corporation like McDonald’s. Then, in order to avoid a long appeals process, they made her an offer behind closed doors that she accepted, but she wasn’t allowed to talk about the case or the award. She wasn’t able to defend herself against what was being said about herself or the case because of that.
@@lauragwillim1055 Don't talk about things you know nothing about.
My father had open heart surgery and was not monitored correctly or given ANY PAIN MEDS, he did not want to be a bother and told me to say nothing. I was not having it. Look after your family when they are hospitalized and speak up. This is so tragic.
My mum had a major reconstruction done and was refused pain meds as well. I wonder whats up with that.
@@derpidot it seems very cruel. Some people legitimately need pain meds
Because pain meds are dangerous to give
@@juliesmith9949 they can be, you know they are non-narcotic pain meds. Also, if used short termed and closely monitored while hospitalized, habit forming pain meds can and should be given. Picture having your chess cut open and your heart valves repaired. You are going to be in massive pain and short term use of pain meds is aceptable. I had my gallbladder removed before the opioid epidemic and was given good pain meds, about two days post discharge I had no need for them. rest. My body had started to heal.
@@FreedomofSpeech865 as an RN I’m responsible for giving pain medications as ordered. I take med administration very seriously.
From cardiac to orthopedic , transplant to mastectomies, it’s serious business, not wish fulfillment.
When my grandmother was hospitalized, our saving grace was my brother's wife, a registered dietician with basic medical knowledge. She routinely called out a variety of errors on the part of my grandmother's medical team (including not reattaching her nutrient bag and leaving her without nutrients for 24 hours while on life support) and this was before the pandemic. When my grandmother needed help, it regularly took 45 minutes to be seen by the respiratory therapist or nurse. It's profitable to have minimal staff and this is the level of care it leads to. I indirectly know two people who were killed by medical errors in hospitals. We need an overhaul of our medical system.
I'm suspicious of the growing "team" approach. They seem to throw in large numbers of staff, rotating in and out while never giving a straight answer. We had this after a car accident and a couple simple fractures... they assigned expensive specialists to a huge team, none would answer questions and no doctor seemed to be in charge of care. Worked out in the end, but very frustrating (and painful) to deal with. Some nice big out of network bills too, for docs who did mostly nothing. I appreciate that complex cases need specialists, but it also seems like a mechanism to increase huge costs while lowering accountability.
@@eh3477 its also frustrating for hospital staff. I am an MRI technologist, and when I question an exam, I get the routine, "I was only on consult, that was not my patient".
@@anniesshenanigans3815 Thanks. Appreciate your inside perspective. I'm guessing it's more due to bad top-heavy administration and management than bad staff. But we only see the staff, and they still gouge us all financially.
I've worked for agencies too, and whenever they assigned a new "team management" scenario to something, projects took twice as long and cost 5x as much. The usual suspects escaped accountability, and anyone who actually was conscientious spent 50% of their time chasing people around for missing info,, rather having time for productive work.
Yes, there is a need for an overhaul
Also skilled nursing facilities where they staff up to 40 PATIENTS to one nurse.
I'm sorry for the loss of your son. Folks, medical malpractice is real and it happens more often than you think. Strive for better pay, better work ethic and environment.
How about strive for a culture of integrity and accountability.
@@yl7495 Do enough people even know what that means?
This world gets crazier by the day!
@@pennycaldwell8141 Corporate hospitals sure have no interest in neither integrity nor accountability. They two things they go for: profit and coverup.
@Bali Breeze this is terrible, OMG, so sorry to know this happened.
Wow docs kill.... no wonder 1m ppl died
My mother got her transplant at this hospital and we had no issues. I feel like this man’s team completely dropped the ball. I was under the impression UCSF was the best of the best. Apparently I was wrong. But they did treat my mother pretty well in 2010 when we were there. I just wish this man received the same awesome treatment my mother received.
I hope all involved loose their medical license like the POS they are
That was 2010...
@@rhondaschaaf4617 you can read, good!
2010??! Take a seat. I was there last week it’s a shit hole
You all seem upset that not everyone had a bad experience.that’s weird
I’m a nurse and I can’t understand why another nurse wouldn’t monitor the patient!! 😡😡 Just
last week I had a patient come up from the ER. Her vitals were stable when she got to our floor. I read in her chart that she was a diabetic and saw fried chicken in the room when I entered. The ER failed to tell me that they also found her to be hypoglycemic. Patient told me they gave her food but I didn’t see where they rechecked her blood sugar after giving food. I did see that they gave her IV glucose. I check her blood sugar and it’s 749! 😔
Moral of the story, ASSESS YOUR PATIENTS!
In the state of California if a patient is hooked up to a PCA pump (self administering pain pump) by law they HAVE to be on a pulse-ox monitor. Anyone doing direct patient care in California knows this and this was so much more than an oversight.
If you find a good health care provider, you found a blessing.
These mistakes could also be prevented by providing adequate training for staff and adequate staffing instead of making cutbacks on staffing while hospital administrators continue to make millions.
They do the same thing in schools and daycare centers understaff $$$$
All healthcare professionals out here, WE need to hold the line and always stay vigilant! Think about the orders you are carrying out or giving! We need to advocate for our patients! These are horrifying mistakes.
Also advocate and fight for better working conditions for RNs! One nurse shouldn't have 20+ patients under her care simultaneously while working 24+ hours shifts straight!
Sometimes they aren't actually mistakes, but reckless endangerment neglect and abuse, and some people should be going to prison for them!!! This is hardly rare but rather extremely common. They are just mostly are treated as above the law when caring for patients with less family support, -much like the police actually but at this point probably even more so...
But occasionally they mess up with who they victimize. But it's still usually just a fine and very seldom a prison term like in should be in more then a few of these casses!!!
@@_Just_Another_Guyabsolutely agree. Understaffing is also a huge issue!
Thank you …it was an Ob nurse who visited me after hours to simply tell me after 3 failed inductions…my baby was not engaged…” normally we do not induce babies who are still ‘ floating’ ( head not engaged)….she told me I did not have to agree to a third failed induction….i had a CSection that saved my baby further stress and a shoulder dislocation ….as he was lodged presenting his shoulder
( somehow the floor nurse thought she was feeling the top of his head on exam
it was the larger part of his shoulder)….
Always always ask irritating questions….its good to have well trained seasoned RNs in your family circle ❤
My father went in for a stroke at John Muir hospital months ago and it took them 6 hours to begin operating on him.
They gave us excuses like, “the mri machines had a failure.”
After 6 hours, they introduced us to the surgeon after the sun had come up.
He had multiple complications throughout his stay, but thankfully he is doing better.
Seems like California is covering up the steep decline of quality of care.
I'm glad that your father is doing better.
@crimdor same thing happened to my dad many years ago. He was transferred to a second hospital and died that night surgeon said it had been too many hours of a delay
My father with covid was rejected in ER for addmission as hospital didn't had monitoring bed available. This was in India.
Short staffed?
I've been a nurse for 15 years and they all are! I just participated in the million nurse march but we also need support from families to start marching with us and putting pressure on congress and these insurance companies to start making safe staffing and priority!
I remember after my last c- section I was put in a utility closet because the hospital didn’t have anymore recovery room space and no one checked me for hours. Fortunately I was fine because my then husband who also is a nurse , took care of me. There are so many things that can and do go wrong! Poor guy and sorry to his lovely family for their loss🙏🏻
We’re always taught in nursing school to regularly check the respiration’s of a patient on narcotics. As a matter of fact if their respiration’s are under 12 breaths per min don’t even give it! This is taught in nursing 1. This is why if your tired, or not 100% in good mental or physical circumstances I would not even clock in. I’m a nurse and mistakes like this happens a lot when nurses are burnt out or the facility is understaffed. Smh I rather lose my job then kill a patient due to errors caused by these things.
When you "don't clock in" you increase the work load on the other staff and endanger the patients. I never feel 100% working 13-15hrs without a break. I've been in health care for 30+ years and our work load, the complexity of our patients have made every floor like a step down unit. Most of our patients are obese or morbidly obese and labor intensive. Nurses and CNAs don't show up for work a lot. Doctors write PAGES of orders that we are responsible for validating. I am NOT an MD. Working through covid has left us all with PTSD and the administrations treat us like crap.
Why did the NP write that order and how did pharmacy approve that dose? Why isn’t a patient on opioids and a PCA pump having their respirations and O2 monitored?
This hits home for me because my grandma died in a hospital last month of “complications” of a fall. she only had surgery on her spine to fix a problem with a piece of her lower spine but then she went into an unrousable sleep-like state for months. Then her respirations and HR declined to 0 (why?) and passed. What the heck? People don’t just become somnolent after surgery and then die months later. No diagnosis, and no cause of death determined. Two points where they had the chance to identify the problem, and they didn’t
Yeah they aren’t really giving pain meds anymore they just let people suffer in agony.
I have been laughed at by other nurses for actually standing at my patient's bedside counting respirations. Most nurses don't.
@@invalidname.pleasetryagain122 sometimes an overdose of medications causes an unrousable sleep-like state/coma when in a medical setting, amongst other possibilities.
A few months ago, my buddy's relative went to the emergency room for gout pain and died the next day. They're now being investigated for malpractice and are being sued by the family.
When I was rotating through nursing school clinicals, I encountered a home health nurse who told me her experience being an ER nurse. She told me she hated being in the hospital. The reason was that she found many patients entered the hospital system and never left it. She was traumatized from it and refuses to ever work at a hospital again.
This is why you don't replace physicians (MDs and DOs) with nurse practitioners. A scary trend happening everywhere in hospitals
Again, his entire medical team failed him. From the NP to the pharmacist who approved the order. If it was given stat that’s different but he had a button sooo 🙄
Nonsense
@@juliesmith9949nonsense? An NP isn't as qualified as a physician.
This. 👏🏼. unfortunately hospital CEOS are simply motivated by profits….
We don’t leave each other alone in the hospital. One example of why, I was with my daughter when she was hospitalized and rather out of it. A nurse came in and was about to give her a spinal injection of some kind. That was the first I’d heard of it and it didn’t match why she was hospitalized so of course I refused and told the nurse I believed she was in the wrong room. I have other examples of things my family experienced. Also - just research the current stats on hospital deaths attributed to malpractice and negligence. And that’s just the number that’s been discovered. And, after childbirth my husband always slept in a chair next to my bed every night I was there. During the day he’d stay most of the time but we felt a bit safer during the daytime. That’s when he’d go home to shower,etc.
nurses dont do spinal injections
Nurses cannot give "spinal injections" so your story isn't adding up.
@@nocreativenameideas668 right that's probably why she stopped her
Oh nooo. I can’t imagine the pain his sister feels knowing that him saving her resulted in losing him 😣
I had surgery at UCSF last month. Post surgery, they pump me with so much Fentanyl that I was hallucinating. They gave me a button to press every time I was in pain. Initially, they started with Demerol. It didn’t help with my pain. So, they switched to Dilaudid. It wasn’t helping. I told the nurse, don’t give it to me cause it’s not working. They continuously came in every 4 hours and put it on I.v. I told them… please don’t. Then, they finally switched to oxycodone. Which finally helped with my pain. But, the fact they kept pushing the Fentanyl was crazy. I was hooked on this patch on my back. And I’m supposed to push this button every 15 minutes. That’s too much. I thought I was going to die. Cause I was going crazy with weird nightmares and hallucinations.
can you tell me more about your hallucinations. my dad was given fentanyl untill his organs started failing I wish I knew better .
I’m sorry that happened to you. Sounds terrifying.
This is heartbreaking. He's an amazing brother. Sending love to his family. 🙏
This is sad. Im sorry for the family.
I work in a hospital and its frustrating sometimes that the floor I work on doesnt even have “enough working “ pulse oximeters for all the patients. What kind of care can we provide? Just a side note, can hospitals do better please ?!
Care is constantly delayed because nurses are having to share equipment. If a piece of equipment is constantly used, it would make sense for the hospital to buy more. But monetary greed is their game
I had open heart surgery last year after going to the ER with chest pain. Because of Covid, no one was allowed in with me, so I had no advocate. I have no memory of anything that happened after I arrived in the ER until a couple days after the surgery when I came to in the ICU. They tell me I consented to an angiogram and the surgery itself, but I have no memory of speaking to any doctors or being advised about the heart surgery. Luckily, my care was excellent, and I have recovered very well. Patients are helpless in these conditions. We are at the mercy of health care providers. It's frightening to think what can happen when we are so vulnerable.
Compensation should never be limited by any laws. Two million wasn't enough compensation to begin with, $250K is a slap in the face.
only $250K for malpractice that killed someone... WHAT A JOKE !!!!!! bottom line: nobody is accountable... nobody lost their medical license over this. and it does not even reimburse their attorney fees. so tragic.
I was in the hospital for a day and what I experienced made me scared of the lack of critical thinking that happened during my stay. I'm not going to do it again if I can find another alternative.
Yep. Very smart thinking. A 2016 study out of Johns Hopkins found medical errors to be the 3rd leading cause of death (other studies have found similar). Hospitals often are not the healthy, healing place people think they are.
Sad, I've been a nurse for 20 years and I now work for a private practice but I feel the same way! I've had to advocate for my older family members hospitalized.
What's the alternative then?
I have experienced the same thing, and it was terrifying how powerless I was to do anything about it.
@@penyarol83 exactly, but people get mad when you don’t treat medical professionals like they’re God. They’re still human and don’t know it all.
I'm a nurse and have a great idea. Get rid of the insurance companies and put their profits toward better levels of staffing.
for a considered first world country, we're unfortunately very incompetent in many industries
Yeah and the US medical industrial complex is a huge part of the economy.
Sad but very true.
How are the nurses or doctors that malpracticed paying for this? Why aren’t their names revealed? This is horrible. I wish best for the family.
Doctors are protected, and the nurses are just following the doctors orders. Plus the hospital is too cheap to have enough nurses for the number of patients they have to care for.
@@anniesshenanigans3815 a real doctor would have never make this mistake. The nurse practitioner that treated him is a complete idiot. He needs a real doctor, not some random NP with a masters degree.
@@anniesshenanigans3815 in this case its not the DR who prescribed the meds its NP nurse practitioner
Hospitals protects these medical professionals and they are never held accountable for harming patients
Many medication errors can be avoided if hospitals and any health facility kept safe nurse to patient ratio.
Nurse practitioner shouldn’t be making those decisions !!!!!! And I have NP’s in my family !!!! Medical system is soooo pathetic !!!!
Exactly! He needs a REAL doctor, not some random NP with a masters degree. Tell that NP to work in an urgent clinic instead.
@@lexismith8206 some doctors are dumb as hell don’t think about title and credentials it’s the person and how smart they are
Any narcotic prescribed by a NP is supposed to be reviewed and approved by a supervising MD.
I worked as a RN at UCSF and what happened was not a standard of care on our floor! Patients with a PCA always had a pulse oximeter and were closely monitored!! It is a well known fact that opioids can induce a decrease in respiratory rate and therefore a low oxygen saturation. The PCA machines have a lockout timer on them so supposedly the patient cannot receive an overdose. The medication dosage is individually ordered depending on the patient’s weight, age, medical history, etc., so in theory, the patient can’t overdose. But everyone is different and someone may be very sensitive to the medication - hence the need for very close monitoring and pulse oximetery!! I’ve been retired for over 15 years but that was standard practice on the floor where I worked at UCSF.
It's one thing to accidentally kill someone but to cover it up? Why?
“We’ve investigated ourselves and found no evidence of wrong-doing.”
This is horrific. I feel so sorry for this family. Condolences.
The incompetence is just staggering mind-boggling!
I almost died after surgery,I couldn't breathe or swallow,I'm freaking out and the post-op nurse could care less until the anesthesiologist walked in and yelled at her what are you doing can't you see if you can't breathe and didn't give me my pain medication either so I had to have a visit with the hospital administrator and Dad for my second surgery I told him don't let that woman anywhere near me and guess who is in post-op after my second surgery so God only knows what they did to me! And the abuse I got treated by the nurses was horrible because I told on one of theirs!!
Similar thing happened to me. I got treated like a drug addict because I was on a pain patch. When my gallbladder started giving me horrible pain I went to the e.r. in an ambulance cause I couldn't even stand up due to pain. They sent me home saying I was "possibly seeking narcotics". Next day, my gallbladder burst and I had emergency surgery.. the nurse I had for 80% of my hospital stay ignored me, refused to give me pain meds when they were due and lied about the doctor ordering Xanax for my anxiety. (I had a 12 hour anxiety attacks that prevented me from laying down and all I could do was pace. (I was only supposed to be up to go to the bathroom then back to bed) the nurse said doctor never called her back when she requested Xanax. Come to find out after twelve hours of hell, that the doctor ordered Xanax 30 min after requested by her but she hid it. The next nurse found it.
You need to check your records and get tested for something called “pseudocholinesterase deficiency”. Did you take a long time waking up after anesthesia? It’s rare, but it means you can’t have a few specific types of anesthesia.
If you did take a long time waking up and this happened, I’d go see a lawyer because the anesthesiologist was compelled to tell you about this.
I had a very similar experience, and then had it happen again because the first hospital failed to inform me why it happened. (It takes me about 4 hours to wake up from anesthesia that generally leaves the system in about 4 minutes)
I can’t help to wonder how many ppl passed away this way, the family believing what the hospital tells them, that the patient died because of a “genetic heart disease.” And never find that it was due to mistakes and negligence from the hospital.
$250,000? Wow, a mere smack on the wrist. California is the place to live.
I know at least 3 families who lost a family member due to malpractice here in CA. They send you a check and keep on killing
It's rampant across the nation. OVER 100,000 people are killed EVERY YEAR from medical mistakes. And those are just the ones reported to the government....Lord only knows how many have been swept under the rug.
Oh, I also have to say that that $250K medical malpractice award cap is ridiculous, and doesn't provide much disincentive against carelessness.
As a doctor, I can testify that many hospitals do not continuously monitor the vital signs of patients on opioids, even post-surgically. Many hospitals only have limited resources for this type of equipment, so they reserve this technology for people who have active cardiac issues or need to be in the intensive care. In fact, there can many barriers in place to prevent you from placing a patient in a continuous monitoring unit if they do not meet the hospital's very specific requirements.
gtfo i have a $30 fitbit that can read my oxygen levels on top of everything else!
So this all started with the ordering provider who was a nurse practitioner and not a physician an MD. This is the problem with scope creep. People are dying because hospitals do not want to spend money and instead hire lower level providers like nurse practitioners and physician assistants to do the job of a physician. Then you can’t sue because “it’s out of their scope“ #StopScopeCreep #trainingmatters #scopecreep
While the adverse event was caused by a multitude of failures, the initial error was made by a provider. Nurse Practitioners should not be allowed to practice without physician supervision. And that supervision should not be only nominal due to an impossibly large number of NPs assigned to each physician.
My neighbor received a kidney from his healthy brother, he passed away & his family never got a good explanation for why that happened. He left a large family who all depended on him to support them.
God bless this family, the hospital’s incompetence and indifference makes this so much harder and horrible for the family.
For those of you that don't know, medical errors are the 3rd leading cause of death in this country. If this country doesn't know by now, after the last 2 years, how horrible staffing is in hospitals, underpaid and over worked, tired staff, then you aren't paying attention. Your nurse will be the one to save you life, and they work under awful conditions in many places. Its why I left the hospital many years ago, and nothing has changed. And the other piece that people don't realize, because of horrible incidents like this one, nurses and doctors become increasingly hesitant to give adequate doses of pain medication when its really needed, and pts pain is often left unmanaged, which is a hindrance to your ability to heal and places more stress on your body. We need competent people that have the time to actually care for patients, instead of the ridiculous amount of BS charting that doesn't lead to better outcomes or patient care, and we need to treat those staff properly and pay them what they are worth. And never be afraid to question your caregivers in the hospital, they aren't all created equally and you have to advocate for yourself or loved one
They want more monitoring, yet they don't want to pay for the number of nurses needed to do that.
Huh? Who’s they? And being on a monitor doesn’t change the patient volume, so what does being monitored have to do with staffing. There aren’t designated staff to watch the monitors, nor is that necessary in most settings.
@@iriemo721 watching the video, you can see who 'they' are. and by monitoring I mean nurses, not machines. There are plenty of machines but they are useless without the nurses.
One of my greatest fears after only a handful of exposures to hospitals is having something so horrendous happen that I or a member of my family will have to go back at some point. No one can ever convince me that these "medical professionals" are little more than trained assassins. Some things that should be common sense approaches to medical care are completely lost on the majority of these people. Sadly, too many stories and statistics to share here.
Your not alone in this fear
@@iWantToBelieve... many of us have had similar experiences with careless medics...we start noticing patterns.
Your 'sorry' won't cover that up.
It'll be ok though, not too long till the AI programmes replace your disdainful ilk.
Kudos to NBC. Not at all excessively dramatic with cheesy music. Facts and good reporting. No family should go through this.
Still suffering from PTSD after my unfortunate inhospitable treatment at UCSF, I'm still alive though, and this young man isn't . So very sorry for his family and I sincerely hope his sister can emotionally recover.
I've got PTSD from a hospital experience as well. It is a truly frightening thing.
@@aliciarosemusic So sorry to hear, I'm thinking there are many of us, and mostly women. I sincerely hope you can find a way to heal. Cheers
Why did it take five years to hold this hospital accountable?
Christ.
No pulse ox on a patient who is taking a drug which is known to cause respiratory depression in excess.
No other staff member with the presence of mind to double check that NPs order for safety.
No vitals or assessment for 5 hours?
The only mistake left they could have done would have been the wrong surgery altogether, they made just about every other mistake possible to make.
If this happens at UCSF, imagine what happens at your community hospital.
I’ve only ever had one dose of Dilaudid. And the effects that resulted was the worst medication side effects I’ve ever experienced. The headache was unbearable, nausea, vertigo, every noise and sliver of light was like an ice pick in my brain. It was right after a surgery to repair the 7 abdominal hernias along my C-section wound that I was left with after being infected with a flesh eating bacteria during my C-section. If one dose did that to me, I can’t imagine having that much Dilaudid in my system. He must’ve suffered greatly.
That can be caused by any opioid, and Fentynal is much much stronger than Dilaudid. In fact Fentynal is so potent that it's prescribed in mcg as opposed to mg like with every other opioid. I've never had that effect from Dilaudid.
I work at a hospital and I've administered countless pain meds including narcotics for surgical and medical patients over the years. It's our hospital policy to monitor post op patents or anyone using a PCA on pulse oxemeter. Respiratory staus and cognitive level of any patient getting an IV narcotic pain med get checked within 30 min. Recently I went to ED for chest pain without any GI symptoms. Morphine didn't relieve chest pain much so they gave me small dose of Dilaudid. Oh my! From then on I couldn't stop vomitting. After 6 emesis and strong anti nausea med, nausea finally stopped. People react differently to certain medications and I learned my lesson. Sorry that you had to deal with such an awful infection from a C section. I hope the surgery went well and you've recovered from it.
Too many mistakes are being made and covered up. I've had some incidents in my family that negatively affected my loved ones, but it's almost impossible to prove their mistakes. I'm glad here they did, and gives me hope that something changes to offer the best possible care to patients.
Here in UK no matter what the surgery we wear a oxometer as standard and closely monitored every half hour,blood pressure,temp pulse by a nurse,
My dad was in and out of the hospital for 3 years before he passed away. I joined the doctors assistant school and therefore I do know a bit about medical/medications/treatments. It would be too long to write here what all has happened to my dad at the hospital (wrong medication, wrong treatment, no treatment at all, ignoring him, ect). If I wouldn’t of checked on him almost daily at the times he was in the hospital, he would of passed away much earlier. The mistakes they made were because they didn’t care, they didn’t read his patient dossier, and many stupid mistakes they did.
My mom was diagnosed with lymphoma while I was in nursing school. She was experiencing heart failure due to one of the chemo meds she was getting, my sister and I kept bringing up issue of high heart rates ever since she started her chemo sessions and all the doctor said was drink more water (?). It was halfway through her treatment plan when I went to check in on my mom during a chemo session after school one day. I saw my mom's chest acting abnormally irrational and told my dad to call for the nurse. Idk why they did not see it earlier, they ended up admitting her to intensive monitoring in the ICU. When they found out I was a "nurse", their medical director called us personally to apologize and said he will personally oversee my mom. Apologize for what? Thinking back, he never said why. We are Asian, my parents were immigrants now legalized citizens; they lack medical knowledge. They don't question. Back then I was young and naive too. Now thinking back, I get upset with myself because I should have sued the living hell out of them. My family moved on from the situation and don't care anymore; my mom survived but with heart failure. But to this day, as a nurse, I do not trust the medical system. I do not trust the staff. I can see how easily staff can alter records, make things up, make mistakes, especially in horrible working conditions. This was at Kaiser by the way.
my father was at our local medical center and was supposed to get discharged the next day. that night at approximately midnight we were called and told he had died.
he had a pre existing heart condition but was on medication in the hospital and from what we observed was stable. the official story was that a nurse stepped from the room to allow him to go to the bathroom and she suddenly heard a crash. he had fallen to the ground and apparently after them calling code and attempting to resuscitate him they called us to inform of his death.
it was extremely unexpected and sudden and his death has adversely impacted my families life and socioeconomic status. and we were just told "sorry" and no autopsy was performed as the doctor on call just attributed his death to "a heart attack" from his preexisting congestive heart failure. i wonder if there was more to this story then what we were told and if there was more that could have been done to prevent his death
I have 4 friends who work in the hospital and after hearing many shameful stories I will never trust or respect hospital staff ever again, shame on them
This happened to us! Pls be your family member’s advocate, don’t leave them in the hospital thinking they will be properly treated and cared for. The doctors do not always communicate with the nurses well and esp when rotations are switched and the life saving medication was not issued to my family member. The doctors and nurses make mistakes esp when you have an overworked doctor not giving the attention and care to your family member and when you have multiple different nurses on different rotations for your loved one who has been hospitalized for over a month, it is critical that you trust your gut and make sure the doctors and nurses are giving your loved one the proper medication and life saving treatment and that they are communicating to you so you know what your loved one should need and can make sure it is met by the hospital staff. Be your loved one’s advocate!
Something needs to be done so that people who are in accidents or are there alone are safe if no advocate present to oversee treatment. In addition to protections for everyone.
Thank you for sharing your story. We have to monitor our loved ones in the hospital. So sorry for your loss of an heroic son.
That is true but if you have no medical background, you are at a loss to know if the prescribed treatment is correct or not. And god help the person that has no family to sit with them.
I was recently in the hospital and I had to tell the nurses to wash their hands. If they aren't doing that, what else are they neglecting?
This is why nurse practitioners who have 1/10 of the training, should not be practicing in place of physicians with NO physician oversight. These are not uncommon stories y'all...
Exactly! He needed a real doctor, not some random clueless nurse with a masters degree. NPs should never replace the roles of a real physician!
This is absolutely sad!! That's why I don't trust hospitals because they have to many medical errors. This guy should have walked out this hospital, and he didn't. My heart is goes out to the family.
A real doctor would have instantly recognized that he was having an adverse reaction to the drug. The nurse practitioner treating him was an idiot.
Lawyers will tell you that you are Not able to sue because in order to win, You Must show
Deliberate Intent to Harm.
This Should Not be Accepted as so Many Families suffer and then, have no recourse!
Shameful!
I’m so so sorry this happened to him. Bless his family and his mom.
I am a physician, Nephrologist, and will be specializing in Transplant after my training.
One thing I can say is that I need to better understand the dosing of the dialaudid. That part confuses me.
Also monitoring vitals and pulse ox depend on level of care at my hospital. General- every 6 hrs
Intermediate- every four hrs
ICU- every 1 hr
And many pts are not on continuous pulse oximeter unless they present with an apparent clinical need to watch their respiratory status continuously
The one thing that I can say for sure is that I am very surprised that the code team did not think of Narcan.
This is a very tragic situation.
I don't fully understand what happened but it's all very tragic and sad. I see people give kidneys all the time and they usually do great and leave the hospital after some days.
The medical field is a scary career tbh.
We vow to not do harm
But unfortunately things like this can happen
And the mixing of various medicine. And not putting a button with remote control so that the patient press for medicine when the patient is NOT a Doctor! Any patient an also fall asleep and press it by accident! Not too smart to have a remote control like that, the job belongs to the staff
You can literally feel the sisters pain in your gut when you look at her!! I pray that the family is able to somehow find peace in this situation and know he wanted you to LIVE thats why he gave you his kidney!! Make him proud!!
NPs shouldn't be allowed to treat inpatients
We have plenty of wonderful NPs. It’s too bad this one didn’t check the side when putting in the order. We always have patients on o2 sat monitoring, we check vitals every 4 hours and more as needed. Did this patient go to the ICU after getting his kidney removed? They have a 2:1 ratio and have continuous monitoring on multiple things.
Wow.. what a senseless mistake. I'm not a nurse of doctor but I know your kidneys filter your blood. How did the nurses not know that the body wouldn't be able to filter the drugs properly. And normally someone does not stop breathing after a successful surgery and considering he was on opiates how did they not think of using narcan. I am literally in disbelief. How sad and also scary. His poor sister is going to blame herself too, what a horrible situation.
Why is it just on the Nurses???
@@factsnofeelings9727 because the nurse practitioner gave him over 380% more dilaudid then he needed
@@bigoof8284 My response did not mention the NP at all, you misunderstood. I was responding to the “normally someone does not stop breathing…. How did they not think to use Narcan” comment… making the bedside Nurses sound responsible.
The kidney does not metabolize opioids.....
@@factsnofeelings9727 if you look at postoperative care you understand where I am coming from I think. It is the responsibility of the nurses.
Where are the staff it would require in order to respond to the alarms set up to address an "alarming event"!
Yes, just deny or avoid the primary problem, inadequate staffing, and then expect more from the few professionals left to deal with the "main problem" that hospital administrators are ultimately responsible for.
As in most cases, it's all about the $$$, who gets it, and who doesn't!
What a horrible tragedy. I can't imagine the guilt I would feel as a sibling even knowing that it was the hospital's egregious errors that lead to his death.
I was given morphine for pain in the hospital. I hated every second of it. I kept gasping for air. The respiratory depression was terrifying. The nurse was quite cold when my BF alerted them to my situation.
Yes they are awfully neglectful of dilaudid. They gave it to me post kidney transplant and after one night of use, i rejected it outright because it made me feel terrible. They eventually let me take vicodin pills instead, but then that made me throw up and i had to switch to tylenol. I can’t imagine how any nurse or doctor would overlook this issue.
Hospitals are under tremendous pressure to make money - that means fewer nurses per patient; less experienced staff; less qualified staff; over worked surgeons; fewer tests and labs; shorter hospital days. It used to be doctors who treated patients; now it is health nurse practitioners, and physician assistants, so called mid level providers. So sad. Great work! Sue the hospitals and sue the system. Only such check and balances could keep the medical systems. No one checked his breathing for 5 hours? This is sickening.
So sad, so sick, so outrageous. Ok, UCSF / tell me, how did this patient die then?
So sad, that it takes lawyers and lawmakers to implement a law to do what doctors and hospitals should have done. Ridiculous $250,000. Sue the hospital for $200 millions to give other hospitals a warning.
It happens more frequent than we can imagine. All about cutting corners so they (the medical team) can make more $$$$.
Very sad the way the medical profesion is headed to. My deepest condolences to his family.
My deepest condolences as well. A young man selflessly giving a kidney - and died. Egregious the hospital says the patient did not die if their mistakes. Ok, then what exactly did the young man die if? This case makes my blood boil. Another reason why nurse practitioners should not be managing complex post op patients. Too cheap to hire real doctors?
@@joannabusinessaccount7293 actually its our own lawmakers who made it law that a nurse is allowed to practice medicine without supervision. did you know nurse practitioners do not have to carry the same malpractice insurance as a physician? That means there is no money for any lawyer to go after an incompetent person who never went to med school or residency but has full autonomy to practice medicine.
Even when alarms go off most medical staff just ignore it. I know it's happened to me in the ER and on a unit in the hospital just like most staff ignore when a patient pushes the call bell. I'm very sorry for this families loss and I appreciate them bringing attention to this.
Because every patient thinks he’s the only one in the hospital. When multiple alarms and call lights go off at the same time, they can’t be answered at the same time. This dude couldn’t tolerate pain. If something else was wrong, they would have found it. He died from an opiod overdose which he administered to himself using a PCA pump. Sometimes it pays to bear the pain.
@@Козак-т6сPumps are not supposed to allow you to overdose. You can't just keep pushing it and receive a dose every time.
I thought we weren't allowed to question experts anymore, because they DON'T make mistakes???
Nurse practitioner is not an expert
@@Notthebottomofthetotempole OK,,,,if they were an "expert" could we still question them? Or, is it illegal now?
I had a transplant. Mass General Hospital watched over me closely. I was hooked up to everything ❤❤
I’m glad you made it through! Keep going ❤
THIS IS INSANE!! I had a pulse ox on my finger after a colonoscopy!!
My neurologist overdosed me on Dilaudid and Depakote which I am allergic to and it was noted in my chart. I went into respiratory failure but luckily the respiratory tech was there to give me an asthma treatment and noticed I was quickly declining. Got down to 2 breaths a minute. They administered narcan and I began breathing again. I spent 2 days in the ICU monitoring carbon monoxide. My dad said all the nurse said she she ran in and then called for the narcan was "we're in serious trouble". I should have sued
Scary. Unfortunately stuff like this happens all the time! There are some really really horrible hospitals. I’ve had some horrible experiences myself
So, he was basically dead for 4 hours before they checked his vitals. Crazy.
What is this the dark ages? "Be an advocate for your loved ones while they are in the hospital". I thought that was the job of the medical professionals. Few people have years of medical training to recognize when something is being done incorrectly to themselves or someone else.
Exactly. People are spending tens of $$thousands in insurance costs. Hospitals are raking in enormous profits while people die of very treatable issues. An increasing number of people, due to age or other real-life issues, don't have a person to sit by and advocate for them. What's the solution for those people?
They're still human. People would do better to stop deifying medical doctors.
@@CadaverQT The problem is not deifying doctors. It is expecting people without medical degrees to catch their mistakes!
The family saved one child and lost another. This is an avoidable tragedy.
I am a Filipina USRN here in TN-worked as RN in the middle east for nearly 12 years-check Vital signs before administering Narcotics… monitor every 15-30 minutes for 1 hour then hourly-low result-hold-super basic-super-of course, understaffing can kill-floating nurses can cause errors too- minimize or avoid floating.
Wow. It’s time to tell the public. These errors are more routine than we thought. Just slow down and check your numbers! Seriously.
I’m a critical care physician - there more to this story. There is a lot of inaccuracies being told in this video. If a healthy young adult loses a kidney, the single kidney is MORE than adequate for maintaining the filtration of drugs and metabolites. It changes nothing about the doses needed for treatment. This sounds like a negligent nurse practitioner. Now, we are going to have MORE unnecessary policies and rules that will only amount to increased spending that is unnecessary. Not EVERY patient on an opiate needs monitoring…how about we hold these people accountable instead of punishing EVERYONE, including the patients. Because, guess who has to foot the bill for all of this additional monitoring? The patient or the tax payers…
Agreed. The NP should’ve have went to actually examine the patient instead of just changed the pain med so carelessly.. not sure how Cali law works but NPs are dangerous when fully autonomous, or being supervised by overworked physicians which is usually the case
Blame the NP. Every rule is because someone didn't do their job, and rules had to be made to make sure people actually do what they're supposed to.
The pop up texts by the news channel referencing 18,000 deaths and inpatients needing monitoring (around the 7 minute mark) are misspelled as "Opiods" rather than "Opioids". If this employee were a medical employee that person could have made a lethal error. If that person's coworker or supervisor caught that error it would have been a "near miss" and the patient would still be alive. I agree with the previous poster that the patient should have been on the SICU floor post-op. Maybe there was limited availability that day or since he was a young, healthy donor that precaution was deemed unnecessary. Regardless, this generous, vibrant young man lost his life, and I hope the new safety measures put in place (which seem like monitoring 101 to me) are never breeched again at this hospital or elsewhere.
THIS IS MURDER. MANSLAUGHTER. IM JUST CRYING.
Sadly these days you just cant leave Loved ones alone in the hospital..My daughter had a Brain Tumor removed 5 years ago and I stayed the whole time and checked everything they gave her..she is a three time cancer survivor and I know how many mistakes they make all the time and she almost died from an overdose of pain killers they gave her..this is so sad for this family.
Yes family is d only support... frankly often med staffs treat d families as if they are fools n just ignore them
This absolutely heartbreaking. My mom was a Kidney recipient and although I no longer speak to her donor I will always be thankful for her selfless act of giving my mom the gift of life and thusly 25 more years with her. To give this gift is one of the most amazing things a person can do for another person. It is life changing. Life saving. I cannot imagine the heartache of this family. This should not have happened. One thing that was said that was 100% true in this is that patients need family members to BE THERE and to advocate for them when they are in the hospital. Remember that your family member is one of hundreds of people on the hospital and many hospitals (especially now) are under staffed. I learned this is my mom’s last few months of life. She was in the hospital for 30 days straight and had I not been there I know her stay would’ve been ten times harder. Please pay attention. Ask questions. Share your observations. The nurses can only do so much.
Poor sister… so sorry for her, her brother, mother and ALL who mourn him.
Salem Hospital in OR will push fentanyl into your iv before you even ask for any pain medication and if you deny it, they give you an attitude about why you don’t want it, despite not being hooked up to any monitors. I physically stopped the nurse from administering it, he did not inform me of what he was doing to begin with, and the doctor came storming in yelling at me, “why don’t you want the pain medication?” I had to repeatedly tell staff I do not want pain medication, and they would inform every new staff through the night, # 49 doesn’t want pain medication. As if I was a freak for wanting answers and not drugs.
Back in 2014, my dad got in one hell of a car crash almost falling off the side of a cliff leaving the car completely destroyed. The hospital staff “forgot” his pain meds (after breaking his wrist, part of one arm, the base of his back, and other injuries). He had no pain meds for 48 hours and it took an additional day of waiting for the hospital to contact the surgeon on my dad’s case to get authorization for the pain meds. Apparently they didn’t want to disturb the dr’s weekend, never mind the extreme pain my dad was in.
Now all news channel will dig all the medical errors that lead to death.
I don’t understand why there was no pulse oximeter on him . That is standard practice for post op patient .someone was slacking. The amount of IV pain medication are given are basing on weight and not how much one can tolerate.
I feel terrible that this happened to the organ donor who is also family. So sad
I hope the sister finds peace. Her brother wanted her to live out her life. The surgery had nothing to do with his death; it was an error after.
And people still don’t think that other nurse deserved to be punished. This malpractice happens all of the time. Her case just happened to make the news.