After a dialysis session in July 2010, a 79-year-old patient with a history of kidney disease was admitted to the hospital’s ICU and experienced shortness of breath. The next day, he reported an “upset stomach.” Although the physicians prescribed an antacid, a hospital nurse allegedly administered a paralytic called pancuronium, according to the report.
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The paralytic caused the patient to go into respiratory arrest. Although he was resuscitated, he remained in a coma for a month before his death, according to the report. The nurse in question was reportedly retrained and fined but continues to work at the hospital. The hospital has also removed the paralytic from all nursing areas so it is handled only by anesthesiologists in the operating room.
The hospital self-reported the incident to the Florida Agency for Health Care Administration, which conducted a review of the error. The agency’s resulting report showed numerous deficiencies by the nurse and the hospital, including failure to “match the patient’s ID with the scanned medication.” The agency also said the hospital’s pharmacy lacked a reason for storing the paralytic in certain areas of the hospital.
The family of the patient has since filed a lawsuit against the nurse and North Shore Medical Center.
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