A Pennsylvanian couple has launched a medical malpractice suit after the man, in hospital at the time with Covid, was given a paralysing agent by mistake, resulting in catastrophic side effects – and a reminder that errors can occur at any stage of the medication process, from prescribing to dispensing and administering.
In September 2021, Didier Epopa, now 55, was being treated for Covid-19 at Philadelphia’s Mercy Fitzgerald Hospital. On 25 September, a nurse hooked up a bag labelled Remdesivir to Epopa’s IV. Epopa had already received four doses of Remdesivir and was due to be released after this fifth dose.
However, reports MDLinx, the bag had been mislabelled.
Instead of Remdesivir, Epopa received a dose of the muscle-paralysing agent cisatracurium. When a nurse returned to check on Epopa, he was experiencing seizures. His heart had stopped.
A “Code Blue” was called, and medical staff resuscitated him about 11 minutes later. He was intubated and moved to the ICU.
Recalling the event, Epopa, a lawyer, originally from Cameroon, said he felt his body seize up and his muscles stop responding. He was unable to use his call button or open his mouth to call for help. He reported feeling as if he were being buried alive.
Due to pandemic precautions, neither Epopa’s wife, Edwige Tsafack, nor his teenage daughter were with him when his heart stopped. In fact, they were planning to take him home later that day.
However, when Tsafack called the hospital later, she heard that her husband was in critical condition, a doctor telling her he had suffered an anoxic brain injury, respiratory failure with hypoxia, and liver shock.
Epopa remained in the hospital for more than a month. Progress was minimal. During this time, doctors reportedly told Tsafack it was unclear why her husband’s heart had stopped.
Then, in late October 2021, the leftover liquid from Epopa’s 25 September IV bag was tested, leading to the discovery of the critical error.
Medical records show that Tsafack was told about the error on 27 October 2021. Disclosing known medical errors to patients is required by state law.
On 3 November 2021, Epopa was transferred to Kindred Hospital, a long-term care facility. He was still using a ventilator when he was admitted and remained on it for more than two weeks until the staff successfully weaned him off it.
He did not return home for another four months, and required extensive therapy to relearn how to talk and perform other daily tasks.
He developed multiple bacterial infections and diabetes during his hospitalisation.
Once an avid runner and biker, he now requires assistance for many physical tasks. He is unable, for example, to hold a pen or spoon steady.
The state of Pennsylvania, Mercy Fitzgerald Hospital, Trinity Health Mid-Atlantic, and Mercy Fitzgerald’s parent healthcare organisation all have rules in place to prevent medication errors such as the one Epopa experienced.
Records show that many of these regulations were followed. The nurse who administered Epopa’s medication checked the prescription, scanned the medication label on the IV bag, and then took steps to confirm Epopa’s identity before hooking up the IV bag.
However, the bag had been mislabelled by a pharmacy intern. Reportedly, the intern still has active pharmacy intern certification, and no action has been taken against their licence.
It’s unclear if the state Board of Pharmacy is aware of the error.
Under state law, Epopa’s case would have triggered a serious incident report to the Pennsylvania Department of Health, however, the state chose not to conduct an on-site investigation at Mercy Fitzgerald after the incident.
Recently, Epopa and Tsafack filed a malpractice lawsuit against Trinity Health Mid-Atlantic and three other Philadelphia-area hospitals. The suit names the pharmacy intern and the supervising pharmacist on shift. Trinity Health Mid-Atlantic has not commented on the suit.
Medication errors and liability
It’s estimated that between 7 000 and 9 000 people in the United States die every year as a result of medication errors.
Costs associated with caring for patients with medication-associated injuries exceed $40bn per annum.
In a hospital setting, medication orders start with a prescribing doctor and then go through a dispensing pharmacist and administering nurse before reaching a patient. An error can occur at any step along the way, and any of the professionals involved can be found liable.
Typically, it’s ruled that explaining the medication and any possible side effects and interactions is the physician’s responsibility, and that preventing wrong dosages is the pharmacist’s responsibility.
In some cases, suits are brought against pharmacists and physicians, determining where liability rests left to a jury.
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