I think I am going to be sick

[The Hen]

How could this happen? Hospital blunder turns a family's joy into heartbreak
August 21, 2010


A horrific medical mistake during the birth of her child has left a Sydney woman in agony - and her infant son without his mother's embrace, reports Julie Robotham.

ALEXANDER ZHENG'S cot is still unassembled in a Hurstville apartment where he has never been.

Home, for now, is a bassinet wedged into a room in the high-dependency unit of St George Hospital, where the two-month-old's mother lies catastrophically injured.

Grace Wang's spinal canal was injected with powerful antiseptic instead of anaesthetic, in what should have been a routine epidural to ease the pain of her first child's birth.

The Herald understand the two substances had been transferred to separate metal dishes on the sterile table, contravening the standard practice of drawing them directly from their packaging into a syringe to avoid confusion.

The devastating medical mistake - inconceivable in its magnitude - has poisoned her nervous system, leaving the 32-year-old distressed, confused, in shocking pain and unable to walk or even sit.

She has lost the strength to hold Alex and rarely asks about her baby, as she did constantly after his birth.
Grace Wang, who is unable to care for her son.

And the future may not bring relief, as Ms Wang's physical and psychological condition has deteriorated since the accident on June 26, and new symptoms continue to emerge.

In the first three relatively hopeful weeks, her husband, Jason Zheng, cooked for Ms Wang and fed and changed Alex, who has apparently not suffered from the drug error.

Ms Wang has undergone surgery to relieve fluid pressure on her brain, and Mr Zheng maintains a vigil beside his increasingly frightened and disoriented wife, leaving little time for his son. The longed-for baby - who followed three miscarriages - is cared for by a nurse the hospital provides. The couple have no family in Sydney, where they migrated from China.

''It's like we are ignoring that we have a son,'' said the distraught father, who will begin legal action.

''If my son has a memory, I don't think he remembers he has a father. But I think he can still remember his mum's smell.''

Alex snuggles close when placed alongside his mother, but breastfeeding has been impossible, for fear the many medicines she is taking may affect the milk.

''Every day she's suffering and she says she wants to give up,'' Mr Zheng said. ''She was crying last night when she touched her son. I just want to change my body to hers.''

Another thing Mr Zheng wants, and which motivates his decision to speak publicly, is to make contact with anyone who has suffered similarly, in the hope their doctors may advise on Ms Wang's treatment.

Epidural administration of chlorhexidine - used to clean skin before injections and strong enough to neutralise resistant hospital bacteria - is so rare that Ms Wang's doctors have identified only one other case.

Angelique Sutcliffe, from Britain, was paralysed for life after the chemical entered her epidural in 2001. But this was just a droplet - a fraction of the eight millilitres infused into Ms Wang.

Managers at St George Hospital yesterday admitted error and pledged to support the family, but would not explain the possible source of such a fundamental mistake in a commonplace procedure: anaethesists conducted nearly 40,000 epidurals in 2006, most recent NSW statistics show, in 43 per cent of all births.

The Minister for Health, Carmel Tebbutt, said: "This is an extremely distressing case and I offer my sincere apologies.''

Internal and external investigations had been ordered ''to discover how this could have happened'', Ms Tebbutt said.

''I want to ensure this case is investigated as comprehensively as possible so that we can make any changes to ensure it never happens again.''

I can not begin to conceive the pain this woman is in. Many heads should roll.

[Lord Jim]

The Minister for Health, Carmel Tebbutt, said: "This is an extremely distressing case and I offer my sincere apologies.''

Well, that's alright then....

That guy must be gunning for The Tony Hayward Award....

[The Hen]

I well remember my epidural. It was from hell and they used an anaesthetic in the first place. They managed to hit a nerve though and I swore my foot was on fire.

A most disturbing experience. I can not IMAGINE the pain this woman is experiencing at what should be the most joyous occasion of her life.

[@meric@nwom@n]

The Herald understand the two substances had been transferred to separate metal dishes on the sterile table, contravening the standard practice of drawing them directly from their packaging into a syringe to avoid confusion.

What? WTF? in a metal dish???? WTF were they thinking? Am I understanding this, they let an injectable sit out in an uncovered metal dish? WTF????

[Lord Jim]

What? WTF? in a metal dish???? WTF were they thinking? Am I understanding this, they let an injectable sit out in an uncovered metal dish? WTF????

I guess they were all out of empty beer bottles....

[BoSoxGal]

Words escape me.

[dales]

Very tragic and totally avoidable.

The bungling retards who did this should face prision time and the hospital's director shoould off himeslf.
Like a/w wondered:
Who the hell leaves ijectable medication in a metal tray fercrisakes?

[Scooter]

What? WTF? in a metal dish???? WTF were they thinking? Am I understanding this, they let an injectable sit out in an uncovered metal dish? WTF????

Somebody who thought they were cooking heroin, maybe?

I think they meant that the two syringes were filled and then laid in dishes side by side, rather than bringing the medications in their packaging and filling the syringes at bedside.

[@meric@nwom@n]

I am not sure but I don't think so Scooter. Why would an antiseptic be drawn into a syringe? Typically betadine is just rubbed over the area prior to the injection of the anesthetic.

None of it makes any sense to me at all.

[Scooter]

Why would an antiseptic be drawn into a syringe?

(knocks self in head) Oh yeah, that definitely makes no sense.

I found this study on skin disinfection before epidurals, and at least it explains why the chlorhexidine would have been poured into a dish - to soak the sponge sticks used to prep the injection area. But for someone to stick a syringe into the dish and draw some out? I don't get it.

[loCAtek]

With my (very) limited medical knowledge- Would a blood transfusion help?

[@meric@nwom@n]

Why would an antiseptic be drawn into a syringe?

(knocks self in head) Oh yeah, that definitely makes no sense.

I found this study on skin disinfection before epidurals, and at least it explains why the chlorhexidine would have been poured into a dish - to soak the sponge sticks used to prep the injection area. But for someone to stick a syringe into the dish and draw some out? I don't get it.

So this leads me back to picturing that they had poured out both the antiseptic and the anesthetic into pans. This makes no sense either unless they are letting housekeeping assist with procedures now.

Another alternative is the story is not being reported correctly.

[@meric@nwom@n]

This story has haunted me since learning of it. It is absolutely unfathomable that this type of error could occur. No one in his/her right mind would ever pour an injectable into a metal pan. Injectables are kept in vials or similarly closed systems for a reason-so that they remain sterile.

It almost makes me wonder if there was some kind of intent going on. I can't find anything else out there that identifies who did this and what action was taken against them.

[Lord Jim]

This makes no sense either unless they are letting housekeeping assist with procedures now.

[@meric@nwom@n]

Thanks steve.

[Lord Jim]

I don't see the justification for that slam @W....

You made a sardonic remark about "housekeeping", (ie the janitorial staff) being involved in medical procedures, and I immediately thought of the House episode where he did exactly that (well not procedures, but diagnosis) and posted a picture from the episode...

How is that supposed to make me like Steve?

[@meric@nwom@n]

Posting pictures instead of a thoughtful response might have been what led me down that slamming path.

[loCAtek]

THE medication practice that led to the catastrophic neurological injuries of a Sydney woman, Grace Wang, during an epidural was phased out of other hospitals more than a decade ago.

Ms Wang was poisoned during the birth of her first child in June at St George Hospital when an antiseptic skin preparation was accidentally injected into her spinal canal in place of an anaesthetic. The case has rocked NSW Health and shocked the public.

The two substances - both clear liquids - were placed in separate dishes on a sterile table in the delivery room, the Herald has learned, and were mixed up as a consequence of being unlabelled. Other hospitals insist drugs are drawn by the anaesthetist directly from their original vial or ampoule into a syringe.

The head of anaesthesia at Westmead Hospital, Peter Klineberg, said yesterday the practice of drawing medications from stainless steel dishes was routine a generation ago. ''It was identified as being an undesirable and unsafe practice.''

The antiseptic infused into Ms Wang's spine, chlorhexidine, has increasingly been used in the past five years in NSW because it mixes readily with alcohol, which accelerates drying and the epidural catheter can be inserted sooner.

The chlorhexidine wrongly injected into Ms Wang, who has suffered severe pain and can no longer walk, is understood to have been mixed with alcohol.


Her husband, Jason Zheng, said she was extremely distressed and was vomiting during her labour, and needed pain relief urgently.

The shift to chlorhexidine has been controversial, and a senior anaesthetist told the Herald betadine - the yellow iodine-based antiseptic which is easily distinguishable from clear epidural drugs - was probably safer.

NSW Health's medication policy states that in general ''the same person must select a medication, administer the medication and record its administration'', but if a nurse prepares drugs the prescribing doctor is responsible for checking them. Someone other than an anaesthetist prepared Ms Wang's drug, the Herald understands.

[Big RR]

I saw that too Lo, but it still doesn't make sense. In my entire life (and I think that would be several generations), I never recall getting a shot at the doctor's or in the hospital that was not drawn directly from a labeled sterile vial. Even if the metal bowls were sterile, other than for billing purposes (a whole bottle dumped into the bowl could be charged whether it was used or not--but then ustralia has national health care) I fail to see what advantage would be conferred over taking it directly out of the vial. Now if the anasthetic were compounded or mixed in the bowl, I'd guess I could see a benefit, but by all accounts that does not seem to be the case here. Maybe it's an ancient, senile anesthesiologist running the show thinking it was still 1915?

[loCAtek]

The last line says it all,

Someone other than an anaesthetist prepared Ms Wang's drug, the Herald understands.

Further research;

Westmead Hospital is one of the largest Australasian Level 1 Trauma Centres. It is a Sydney University Teaching Hospital and a 750 bed tertiary referral centre. We serve a population of 2 million people and average over 2500 trauma admissions per year. One of two well-established Helicopter Retrieval Services is on Campus. We run 6 EMST/ATLS courses per year and can also provide, if requested, paediatric trauma experience since the Westmead campus is joined by Sydney’s largest Paediatric Hospital and Trauma Centre.