State Study Details AIDS Needle Mishap at Mercy

Improperly trained technicians, sloppy lab techniques and a lack of written procedures are to blame for a young woman’s injection with a syringe used on an AIDS patient at Mercy Hospital last September, state investigators report.

For the first time, the state report lays out the chilling chronology of how the mistake was made and some of the reasons the woman wasn’t notified of it for 36 hours.

Based on an October inspection, the report this week from the licensing and certification division of the State Department of Health Services says the error occurred because a nuclear medicine technician recapped a used syringe before placing it into its protective lead container.

It is routine hospital procedure not to recap used syringes, so they won’t be mistaken for sterile ones.

Compounding the problem, it says, a second technician failed to read the name label on the syringe before taking it from atop a small refrigerator and injecting the woman with it to diagnose the reason for her back pain.

Shortly after her injection at 11 a.m. Sept. 25, the technicians discovered the error when they found a full syringe with the woman’s name on it, the report says.

That means not only that the woman was injected with someone else’s used syringe, but also that she probably received the wrong radioactive substance for the test she was supposed to have been given.

Instead of notifying the woman’s doctor--as hospital policy specifies--or their supervisor, the technicians took it upon themselves to confirm the error that afternoon with a lung X-ray test that a doctor never requested.

They also decided to inject the woman with a radioactive isotope a second time, this time so she could have the correct test on her back performed.

The reduced-dose level in this second injection was determined by a technician, not by a doctor, and neither it nor the preceding events were recorded in the patient’s chart, the state report says.

Indeed, Mercy’s nuclear medicine technicians at the time routinely failed to document basic data on the tests they did on patients, the report says.

The woman’s lawyer, Harvey Levine, said she was told that the second injection was needed because they had “missed the vein” the first time. But a technician later told the state investigator that “patients are not told (of errors) because they are not at risk,” the report says.

In any case, the woman went home on the afternoon of Sept. 25 with no indication that anything was wrong, Levine says.

It wasn’t until the next morning, a full day after the original injection, that the technicians notified their supervisor of the error, the state report says. No further action was taken until that afternoon.

It was then that a review of records showed that the syringe with which the woman had been injected had previously been used on a person infected with HIV, the AIDS virus. Still, it wasn’t until many hours later--1:30 a.m. Sept. 27--that the woman was awakened at home and called to the hospital to be told of her potential exposure.

Neither the hospital nor the state report explains the reason for that additional half-day delay.

In addition to revealing details of the incident, the state report delineates a host of deficiencies in procedures and policies in the hospital’s nuclear medicine department.

All five technicians performing the tests during October had not taken a required course in intravenous therapy procedures and protective rules, the report says.

Even if they had, the hospital had inadequate written policies on these radioactive tests to teach the technicians, it adds.

“There was no written policy and procedure for the preparation and administration of intravenous radioisotope agents; also there was no written procedure for the handling and disposal of used syringes and needles (afterward),” the report says.

In particular, the Mercy nuclear medicine technicians were routinely recapping used needles, it says. This increases the chances of a used needle being mistaken for a sterile one, as occurred in the AIDS incident.

The state report was delivered to Mercy Hospital on Wednesday. The hospital must respond to the state with a written plan for correcting the licensing deficiencies, the inspection found.

“The deficiencies . . . were corrected soon after the incident was discovered. We are currently in the process of documenting these corrections with the state,” Mercy’s chief operating officer, Mary Yarbrough, said in a brief written statement.

The technician who failed to look at the label before giving the woman her injection is no longer with Mercy, but officials there will not say if the person was fired.

Attorney Levine, who said he plans to file a lawsuit on behalf of the woman within the next month, said he feels the report belies Mercy’s attempts to characterize the incident as an isolated accident.

“The hospital wants to refer to this as human error,” he said. “It’s not human error when you don’t supervise people working with radioactive materials. That’s a conscious decision on the part of the hospital to inadequately supervise an ordinarily well-regulated diagnostic area of the facility.”

Levine said his client has already received vaccine against hepatitis and treatment with AZT, an antiviral drug that doctors hope prevents infection in such cases.

On Friday, she had her first blood test to see if she is infected with the AIDS virus. Results won’t be available for about 10 days, he said.