|Mary L. McClinton's story highlighted in nurses' national effort to prevent medical errors|
The family of Mary L. McClinton, a Seattle-area woman who died as the result of a preventable medical error at Virginia Mason Medical Center is lending their mother's tragic story to a national campaign promoting improved patient safety procedures. On June 22, the Association of periOperative Registered Nurses (AORN) is urging healthcare professionals around the nation to focus on reducing the risk of medication errors in operating room settings, with particular emphasis on incorrect and inconsistent labeling.
To the family of Mary L. McClinton, the campaign means that other families might avoid the preventable pain and death their once-vital mother suffered. McClinton died on November 23, 2004 at Virginia Mason Medical Center, almost three weeks after a non-surgical procedure to treat a brain aneurysm. In what the hospital itself called an "avoidable mistake," staff at Virginia Mason injected McClinton with a toxic cleaning solution instead of either saline or the radiological dye routinely administered at the conclusion of the procedure. Prior to her death, McClinton suffered 19 days of unremitting pain, a stroke, two cardiac arrests, and in a belated attempt to save her life, the amputation of her leg.
"Our hope is that nobody else should have to go through what our mother did and that all hospitals label all medications, containers and solutions," said William McClinton, Mary McClinton's youngest son. "Unfortunately for our mother, no one bothered to "take time out" before her procedure. If anyone in that operating room had, she would still be with us."
National Time Out Day is part of AORN's ongoing effort to curb the alarming number of deaths and injuries due to medical errors. This year's emphasis on medication errors was prompted by a survey of 1,600 hospitals conducted by the Institute for Safe Medication Practices that found that only 41 percent of hospitals always label medications and solutions used in operating room settings. According to this survey, An alarming 18 percent of the hospitals do not label containers at all and another 42 percent apply labels inconsistently.
On November 11, 2004, seven days after Mary McClinton was injected with the antiseptic Chlorhexidine, in an e-mail distributed to Virginia Mason staff and later obtained by the family, hospital administrators explained that the error occurred because Virginia Mason did not label the containers holding solutions, and that McClinton's condition was due to "the consequences of an avoidable mistake that caused massive chemical injury to her leg at the end of her procedure."
"While no single person is responsible, all of us are responsible," the memo stated. "Many were aware of the hazard in the system that could lead to injection of the wrong solution and aware of a simple method to prevent this occurrence. No one took action to change the process before this tragedy occurred."
To the McClinton family, the apology was hollow. The family filed suit against Virginia Mason Medical Center and Dr. David Robinson on March 22, 2005. The case is slated to go to mediation in early August, according to the family's attorney, Lawrence M. Kahn of Bellevue, WA.
Learning the mistake that killed their mother could have been avoided with a mere label, the family vowed to get involved in promoting greater awareness of patient safety procedures such as labeling. As Michael Cohen, President of the Institute for Safe Medication Practices, recently observed, "Use of unlabeled containers and resulting mix-ups of various kinds of look-alike fluids have been implicated in patient deaths and injuries for decades and always pose a danger." The choice not to label is "totally unacceptable in any hospital," he said.
A tireless volunteer and civic activist, Mary McClinton devoted her life to helping others. Born and raised in Arkansas, McClinton was a professional social worker who worked in Alaska for almost 30 years. While raising four sons, McClinton fostered several children and worked to help countless others. McClinton was an advocate for the disabled, poor, and Native Alaskans.
The McClinton family has established the Mary L. McClinton Foundation to carry on Mary's good works. The Foundation will focus its efforts on helping those in need where Mary McClinton's impact is most sorely missed: Southeastern Alaska and the Greater Puget Sound.
For more information on Mary L. McClinton and the Foundation, please contact the family spokeswoman Susannah Peskin at 206-851-2256 or via email at: firstname.lastname@example.org. For a free copy of the video that documents Mary McClinton's ordeal at Virginia Mason Medical Center, "Mary McClinton: The Last Nineteen Days," please contact Peskin. For additional information, visit www.marymcclinton.org and www.nationaltimeoutday.com/2005/.