Deadly Mistake Averted: Leads to Better Procedures at Hospital

PA Corey Asbell Makes Personal Experience an Opportunity for Improvements

Oct. 11, 2018

By Hillel Kuttler

On February 5, Corey Asbell walked into Jefferson Healthcare Hospital, something he’s done thousands of times in the past 19 years as a PA in family practice and internal medicine there.

That morning at the Port Townsend, Washington, facility, Asbell entered as a patient. He’d scheduled an arthroscopy for torn cartilage in his left knee. Asbell received a spinal anesthesia and remained awake for the procedure, even watching it on a monitor. Afterward, he felt fine and was discharged. His wife Kristy, also a PA in Port Townsend, drove him home.

Within a few hours, Asbell, 45, nearly died.

As the procedure concluded, a four-drug mixture had been injected in the knee to combat expected post-operative pain. Instead of the mixture including 10 mg. of morphine, Asbell was given 250 mg. The medication error, undetected, caused Asbell to stop breathing when he dozed off at home that afternoon.

Kristy’s alertness saved his life. She rushed him back to the hospital, keeping him awake during the drive by making him sing along to “99 Bottles of Beer on the Wall.”

250-mg. vs. correct 10-mg. dose

Late that evening, with Asbell re-hospitalized, the pharmacist discovered the 250-mg. morphine vial in a trash can in the pharmacy’s sterile room, where the medication was prepared under a sterile hood. With the error revealed, Asbell immediately received a naloxone infusion to counter the overdose.

“I had a classic presentation of opioid overdose and was admitted to the ICU on a Narcan drip in order to keep me alive as I kept having apnea episodes,” Asbell said.

The pharmacist, the surgeon, the hospitalist, and Rena Sleight, Jefferson Healthcare’s director of risk management, all stopped by Asbell’s bed. They “immediately owned up – apologized – as soon as they figured out what happened,” Asbell said. Plenty of other colleagues visited, too.

The next day, Asbell was discharged again. Kristy again drove him home – with an important stop en route. She parked at their daughters’ school, and brought them out for hugs with dad. Asbell still wore light-blue hospital scrubs. They all cried.

When Asbell returned to work only three days later, he met with his colleagues and told them: “I want you guys to know I don’t have any ill will toward you. We have to turn this into a positive.”

He spoke for 15 minutes. No one else uttered a word until the pharmacist asked, “Can I give you a hug?” The two embraced.

“That was powerful. I didn’t ask for their jobs. I forgave them,” Asbell said. “I wanted to ease their pain, and it was therapeutic for me.”

PTSD symptoms due to near-death experience

By June, though, he’d become increasingly depressed, wasn’t sleeping well and exhibited irritability. Asbell said he possessed “all the symptoms of PTSD” due to the near-death experience and the errors responsible for it. In early June, he took leave from his clinical job. Corey, Kristy, and one of their two daughters entered counseling.

Such a patient might have been expected to sue the hospital and win. Instead, Asbell forgave those responsible and worked with Jefferson Healthcare to prevent a recurrence.

Asbell is in prime position to see those improvements through. Aside from his PA responsibilities, he’s served since 2007 as Jefferson Healthcare’s chief medical information officer. He’s deeply involved in overseeing documentation and safeguards to prevent such mistakes in the first place.

Two weeks after returning from his clinical leave, Asbell arranged an informal meeting with director of risk management Sleight, plus one of the hospital’s pharmacy technicians, and one of its pharmacists, to discuss solutions and the opportunity for procedural improvements.

Root-cause analysis to correct error

While Asbell was working through the experience personally, the hospital convened a root-cause analysis, standard for dissecting dangerous errors in a patient’s care and beginning to correct them.

The pharmacy technician had mistakenly taken from the cabinet the clear, 250-mg. morphine vial with its dosage appearing in green, even though the 10-mg. vial was brown with its dosage written in red. Both vials were the same size and carried white labels. The pharmacist, working in the next room and watching the medication’s preparation on a video monitor, had zoomed in on the morphine bottle and approved it, even while not getting a good look at the label.

Under the procedures implemented post-analysis, pharmacy technicians must click medications and dosages in a drop-down menu, and a warning appears requiring confirmation of unusually high dosages. The vial also must be scanned to match the dosage prescribed. In Asbell’s case, a scanner had been ordered, but wasn’t installed prior to Asbell’s procedure. The video camera is now mounted on a wall rather than on a shelf which made it susceptible to shaking and blurriness.

“There were multiple factors that led to this event, the most important being system issues with equipment in the pharmacy,” Sleight told AAPA in September.

In separate interviews, Asbell and Sleight agreed that the most important correction to prevent such overdoses was the scanner’s installation.

Patients’ having a role in root-cause analyses is unusual, due primarily to liability concerns. In this root-cause analysis, Asbell participated.

“What healthcare has fostered is not to be transparent because of the risk of litigation,” Asbell said.

PA patient experience is part of the solution

“It’s really, really important, to take stock, [uncover] the facts and disclose them to the patient,” Sleight explained. “With Corey, it was super-easy because he has that [PA] experience and he was also a patient. He was harmed, but he’s part of the solution. He has the knowledge that could help us fix this problem we experienced.”

Someone commending Jefferson Healthcare’s approach is Sorrel King. In 2001, her 18-month-old daughter, Josie, died at Baltimore’s Johns Hopkins Hospital following a medical error. Rather than sue, King and her husband collaborated with the hospital to learn from the tragedy. Hopkins founded the Josie King Foundation.

“It sounds like the hospital did the right thing,” King, who did not know of the Asbell case until interviewed by AAPA, said of Jefferson Healthcare. “Three great things happened that were right: The hospital apologized, worked with him to find out what happened, and worked with him to address the problem.”

Asbell says he never bore anger toward the pharmacist or pharmacy technician. He considered suing, but realized that would’ve meant quitting the hospital, where so many colleagues are his friends. The Asbells would have had to move. The money wouldn’t have been worth it, Asbell decided. He expects the hospital to extend “fair” compensation for his pain and suffering, but is “not looking to build my retirement nest egg – that’s not my motive,” he said.

“Am I sad I almost died? Yes. Do I think they tried to kill me? No,” he said. “They got complacent in their jobs. In my day-to-day job, I might’ve gotten complacent. We do that in healthcare. We get into a routine.”

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Hillel Kuttler is a freelance writer. Contact him at [email protected].