Pharmacy Lawsuit at Mass General Hospital

An error compounded


By Brian McGrory, Globe Columnist | July 2, 2004

It should have been just another day at Mass. General, one of the world's great hospitals, which is to say, another day of brilliant minds battling ravaging diseases, of hope overcoming heartbreak.

But the sun-drenched morning of Aug. 4, 2000, proved anything but ordinary. Inside the hospital pharmacy, a young trainee unwittingly set off a chain reaction of life-threatening mistakes that, nearly four years later, is still being felt.

In short, the unsupervised pharmacy technician, in her second week on the job, wrongly added insulin to an undisclosed number of intravenous nutrient bags prescribed to sick infants.

The feeding bags contained no indication of insulin on their labels. They apparently were not checked by the pharmacist before delivery to the neonatal intensive care unit. They were then administered to the tiny patients by nurses unaware of the insulin within.

Almost immediately, several of the children around the unit hit a dangerous state of hypoglycemia.

When Margaret and Joseph Stebbins of Londonderry, N.H., walked into the ward that day to visit their prematurely born twins, Nicholas and Amanda, their son was writhing in his bed. Days before, doctors had said he was nearly healthy enough to go home.

Doctors informed the Stebbinses that Nicholas had a setback because of tainted nutrition, the Stebbinses said this week. Neurologists were summoned to stop his seizures. The prognosis was dire.

Four years later, the family copes with what they believe is the tragic outcome. Nicholas suffers from cerebral palsy. He is moderately deaf. His vision is dismal. He can't stand and needs a walker to toddle around. His intellectual development has been impaired. Meanwhile, his sister, who didn't receive a tainted feeding bag, is a normal, healthy little girl.

''The therapists keep telling me they wish every kid would work as hard as him and was such a pleasure to work with," said Joseph Stebbins, who left his job to tend to Nicholas. ''He's a great little guy."

Said Margaret: ''He has a smile that can light up a room."

A hospital lawyer yesterday acknowledged the mistakes, which had not been previously reported.

''These institutions are run by human beings," said John Ryan, a lawyer hired by Mass. General to represent the technician. ''The hospital recognizes that this is a very unfortunate situation. There was a situation that resulted in the inadvertent inclusion of insulin in these bags.

''This was an isolated event," Ryan added. ''Since then, the systems have been strengthened and improved."

But the hospital is providing neither the names nor even the number of patients who received insulin. The Stebbinses said they were told at the time that there were three other infants. Yesterday, Ryan said, ''four, maybe five," and also, ''no greater than six."

The Stebbinses want to know. As part of a lawsuit they've filed against the MGH pharmacist and technician, they're seeking the medical records of the other infants who received insulin.

''The defense can argue that the [cerebral palsy] is because he was born premature," said the Stebbinses' lawyer, Albert Zabin. ''But if you have three kids who have similar injuries, that's good evidence that the insulin caused it."

Mass. General is adamantly opposed. ''The hospital can't, and will not, compromise patient confidentiality," Ryan said.

It's a maddening stance, considering that it's Mass. General that probably injured these patients, and now it hides behind patient confidentiality in refusing to reveal the extent of the mistake.

The Stebbinses suggested that the hospital redact the patients' names and provide only conditions. MGH again refused, and a judge has sided with the hospital. The suit continues.

It was a sad August day at MGH those four years ago. Now the hospital is making a bad situation worse with a cloak of secrecy. The Stebbinses only want to hear from anyone else who was hurt. Hopefully, those people might come forward now.

Brian McGrory
Boston Globe Online edition
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