Group Seeks Report From St. Mary's After Medication Error

Hospital Has To Respond To Federal, State Inquiries

Updated: 4:10 pm CDT July 25, 2006

St. Mary's Hospital has yet another group scrutinizing it in the wake of the death of a 16-year-old pregnant girl who was given the wrong medication at the facility.

videoVIDEO: Watch The Report

Officials with the national non-profit group that accredits hospitals around the country said that St. Mary's has 45 days to submit a report on what happened in the teen's death and how it won't happen again.

The Joint Commission on Accreditation of Health Care Organizations could pull what is essentially the industry seal of approval for St. Mary's, WISC-TV reported.

Late last week, the hospital was cited for several deficiencies by the state and federal officials issued an "immediate jeopardy" warning, saying that patient safety was at risk at St. Mary's.

These stem from an investigation into the death of the teenager who died during labor due to an apparent medical mistake at St. Mary's.

The victim, 16-year-old Jasmine Gant, died during labor on July 5. The Verona High School student was preparing to give birth to her son, Gregory, but was given a spinal epidural drug intravenously by a nurse and died. The state Health Department's investigation blamed a medication error by St. Mary's for Gant's death, WISC-TV reported.

The error has sparked numerous questions from federal, state and other officials. In addition to maintaining its accreditation from the national safety group, the hospital must take action to keep its state license and federal Medicare and Medicaid reimbursements, which on average makes up to half of a hospital's revenues. Those revenues for St. Mary's could stop on Aug. 5, official said.

Federal Report Says Nurse Didn't Use Bar Code Technology

A federal report said the nurse who administered the drug failed to use bar code technology to make sure that Gant was getting the right drug. Regulators said it's policy but not practice, WISC-TV reported.

Bob Herskovitz of the U.S. Centers for Medicare and Medicaid Services, said that facilities must take steps to make sure their workers adhere to the policy.

"We want a system in place to prevent medication errors from occurring. It's there but the staff are not utilizing it," Hershkovitz said. "Just to have (it) in place is not good enough. We want to see them take it up a level. And show us that the hospital is now better able to utilize their system."

Federal officials said that the hospital has until the end of the week to respond to the "immediate jeopardy" warning letter that was issued last week based on the details of Gant's death.

Report Tells How Medical Error Occurred

A report prepared for federal regulators reveals the chronicle of how the error occurred.

According to the report, a doctor ordered an IV started and penicillin to stop Strep B from possibly infecting the baby at 11:15 a.m. on July 5. Half an hour later, the nurse noted that an IV started in Gant's hand. Then 15 minutes later, the nurse noted the start of penicillin, which in reality is an epidural anesthesia only meant to be administered into the lower back and not intravenously.

Just five minutes later, the registered nurses wrote that Gant had a "seizure, jaw clenched and gasping respirations." Four minutes later, a "code team" used drugs to try to treat cardiac arrest and a low heart rate, but nothing worked. An hour and a half later, all efforts stopped and Gant was pronounced dead, WISC-TV reported.

The deficiencies noted are based on investigations done by the state licensing regulator, which is the Department of Health and Family Services.

In addition to federal inquiries, state officials said that they want a plan of correction in less than 10 days.

Stay tuned to WISC-TV and Channel 3000 for continuing coverage.

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