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Medication mix-up may have led to patient death
Quality Improvement Monitor, November 3, 2005
The August death of a 21-year-old man at Santa Teresa Medical Center in San Jose, CA, may have resulted from staff giving him the wrong medication, according to the November 2 San Jose Mercury News.
The county coroner's office is still investigating the death, but state officials said staff delivered the cancer-fighting drug vincristine to Christopher Robin Wibeto's bedside and didn't realize the mistake until after he was injected with the drug, the paper reported. Wibeto died three days after the error.
The JCAHO in July issued a Sentinel Event Alert warning that vincristine could cause death if administered wrong. The JCAHO identifed 37 cases of fatal vincristine errors since 1968.
State investigators found the physician and the nurse failed to confirm the drug was for the correct patient prior to administering it, the Mercury News reported. The state attorney general's office will review the case, the newspaper said.
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