MIAMI – A South Florida family files a lawsuit against North Shore Medical Center after a nurse mistakenly gave a 79-year-old man Pancuronium, a drug administered to inmates during most lethal injections.
Last July, Richard Smith, 79, was admitted to the intensive care unit for observation after complaining of shortness of breath. Records show Smith told doctors he had an upset stomach. The doctor ordered Pepcid, an over-the-counter antacid, for him.
However, a nurse in the ICU grabbed a vile of Pancuronium out of a locked drug cart, injected it into Smith's IV tube and apparently left.
Pancuronium is used in the ICU when intubating patients. Larger doses are given to inmates being put to death.
"You would not lose consciousness, you'd be able to hear and have recall but you would be paralyzed and unable to move," said University of Miami anesthesiologist Dr. Keith Candiotti. "With sufficient dosing, you also would not be able to breathe."
Records show 30 minutes went by before Smith was found unresponsive because his heart had stopped. Marc Smith arrived at the hospital to see his father and was confronted by a doctor.
"He said, 'I'm sorry to have to tell you this, but the nurse administered the wrong medication.' I said, 'How could that happen, didn't he read it?' He said, 'The nurse said the package looked the same,'" Marc said.
His father was resuscitated but never recovered, and died weeks later.
A state investigation revealed the nurse on duty failed to read the label, failed to scan the medication and failed to scan Smith's patient ID bracelet, which would have alerted the nurse of the mistake before it happened. A report also said the nurse failed to follow safeguards on a drug dispensing cart to prevent these types of incidents. North Shore was cited by the state.
"It's one thing to make a mistake. It's another thing to make the mistake and walk away from it and leave this man unattended for 30 minutes and come back and find him cold and blue," said attorney Andrew Yaffa, who is representing the Smith family.
"Our hearts go out to the Smith family for their loss. This was a tragic event that was immediately self-reported to the Agency for Health Care Administration. We conducted an internal review and have several new processes in place to ensure a situation like this doesn't happen again," North Shore spokeswoman Jennifer Beard Evans said.
Local 10 has learned the nurse, Uvo Ologboride, still works at North Shore as a nurse. State records show Ologboride paid a $2,800 fine, received a reprimand, and had to attend remediation courses. The hospital said he has been appropriately counseled and re-trained.
However, Lula Smith, Richard's widow, doesn't find consolation in this punishment. Smith spent 35 years teaching in the Miami-Dade School System. Besides raising their own four kids, they have adopted and raised ten other children in need and were currently raising a 2-and 10-year-old whose mother had recently died.
The house once full of energy is suddenly quiet.
"They took the patriarch of our family away," said Marc Smith.
North Shore has now removed all Pancuronium from nursing areas except for the operating room. A new packaging system was also set up in the hospital. The vial will now be placed in a sealed bag with a clear a warning on the outside.