Fertility: A Novel Page 4

  “When did you next assist Joyce with the Arkin baby?”

  Petersen started twisting her light brown hair around her finger. She hesitated a minute and then began her version of the events of the prior night. “I think it was around 5:30 when all hell broke loose. I was with a little guy who was on a ventilator when I heard the screams and then the code alert. I realized it was the new admission’s room, so I put on a gown and gloves and went in.”

  “Who was in the room at the time?”

  “Let me see. Dr. Smith, Joyce, Jeannie Lopez and the parents. The mother was screaming, I mean hysterically. It wasn’t until I looked at the baby that I understood what was making her act so crazy. God, I’ve never seen anything like that — blood coming from everywhere. Dr. Smith told me to get the parents out of the room. I mean the doctor can’t think straight when people are screaming at him. So I did my best to get them out of there.”

  “What did you say?” Sarah was anxious to hear what this twenty-something LPN could have said to tear Mark Arkin away from his hemorrhaging infant.

  “Well, I said just what I said to you. I told them the doctor couldn’t do his best for their baby with them so upset — that he had to be able to work. The best way for them to help was to give the doctor space. The father started shouting at me, saying he wasn’t going anywhere, that he wasn’t going to leave his kid alone for a moment with such…incompetents. Yeah, that was the word he used, incompetents. Then Dr. Smith yelled at the father.”

  Sarah was intrigued. “What did he yell at the father?”

  Petersen seemed to hesitate for a moment and her cheeks flushed. “You have to understand how bad things were. I don’t want to get him in trouble.”

  “It’s best if you just tell me how things went. I understand it was an extremely stressful situation, Tracy,” Sarah assured her.

  “He said something like, ‘Don’t be an asshole. I am trying to save your baby’s life — and unless you’d like to take over for me, I suggest you get the hell out of here and let me work.’ Just like that. Then the mother shook her head like she couldn’t believe what was happening. She was crying and she told her husband something.”

  “Could you hear what she said?”

  The LPN tried to recall the scene. “I think she said something like the doctor was their only hope. Yeah, that’s what she said. ‘He’s our only hope.’ The father looked like he was about to go nuts, but the mother took his hand and led him out of the room. It was somehow one of the saddest things I’ve ever seen, and believe me, I’ve seen plenty of sad things working here.”

  “And what happened next inside the baby’s room?”

  “Everyone was so busy working on the baby, I figured I’d just do what made sense. I was going to get clean linens for the crib when Dr. Smith told me to get the pharmacy on the room phone and tell them we had an emergency, which I did. Then he said to put the phone to his ear. I did that, too. He told the pharmacy what he needed for the baby — stat — and that he was sending someone to personally get the meds. When he was done I took the phone from his ear. Then he told me to run down and get protamine sulfate.”

  “Do you remember the dose?”

  “Oh, yeah. When Dr. Smith was still on the phone he said something like, ‘This time, try not to send me a thousand times what I’m prescribing.’ He told me to make sure I was getting 100 mg of protamine sulfate. He was very clear about that.”

  Sarah felt like she was hitting pay dirt. It was clear that Dr. Smith was certain the error originated in the pharmacy. Now Sarah had to nail down how the pharmacy’s highly touted computerized medication system allowed these errors to occur — and with such calamitous results for two-week-old Ariel Arkin.

  CHAPTER SEVEN

  The interview with Tracy Petersen, LPN, was done by eleven o’clock. Sarah and Doris had time enough before Jeannie Lopez, the charge nurse, arrived to use the bathroom and get a cup of coffee. Coffee was Sarah’s energy drink and comfort food. It also gave her something to do with her hands. Some people smoked cigarettes to keep their hands busy; Sarah generally had a cup or mug of coffee in hers. An admitted addict, she indulged with abandon.

  Jeannie Lopez added little new information. She, too, heaped praise on Joyce Hilker, calling her one of the finest nurses she’d ever worked with, and describing her as smart and dedicated. She said Hilker was great with the patients and the families, too. Lopez’s own interaction with the Arkin case began when the massive bleeding was discovered. She confirmed the steps that were taken to staunch the bleeding. When asked how she thought the overdose had occurred, she pointed the finger of responsibility at the pharmacy. She said she had no explanation, however, for how Hilker had missed the discrepancy between the labels on the heparin vial.

  Dr. Esther Cho, the attending physician for the baby, was scheduled next, but she was late. Sarah used the time to begin writing up her preliminary findings. About twenty minutes later, a tall, slender woman in her late thirties appeared at the door.

  “I was called to an interview. Is this the right place?”

  “Dr. Cho?” Sarah inquired.

  “Yes.”

  “Please come in,” Sarah said as she showed her to a seat.

  “Can we make this quick?” the doctor asked. “I have some very sick patients waiting for me on the floor.”

  Sarah skipped her usual introduction, started the digital recorder and nodded to Doris. “Certainly. I think we can get right to it. Dr. Cho, I’m interested in your account of the events surrounding the case of Ariel Arkin.”

  “Well, I came to room 405 after the code alert. As I was gowning up I saw an older man and a younger woman outside the door to the isolation room. I assumed they were family. Maybe the grandfather and mother. They were very upset.

  “I entered the room and Dr. Smith brought me up to speed. It was a clear case of a massive heparin overdose. I personally had only read about so large an overdose, and I hope I never experience anything like that again.

  “Dr. Smith and I agreed to administer 1 mg of protamine sulfate via IV for every 100 units of active heparin to reverse its anti-coagulating effects. He’d already put in an order for it. I reminded him to infuse it slowly to minimize hypotension, bronchial constriction and pulmonary hypertension. We also discussed using vitamin K to help stop the bleeding. We agreed on the optimal rate for infusing new blood into the infant to replace what she’d lost. Dr. Smith was on top of it. We were successful in our efforts to stop the bleeding. This morning, the baby is stable.”

  “Thank you, Dr. Cho,” Sarah said. “Do you have an opinion on how the overdose occurred?”

  “If I were you, I’d focus on the pharmacy.”

  “And what about the new computerized system for medications? How could it have failed to prevent the overdose?”

  “It’s beyond my purview to have an opinion on that,” the doctor said curtly. “I think the person you want to talk to is Joanne Marsh, the head of the pharmacy. She was the new system’s biggest booster.”

  “And the baby’s prognosis?” Sarah asked.

  “Given her response to treatment, I’m guardedly optimistic that she’ll recover, hopefully without permanent damage.”

  * * *

  As Esther Cho left the conference room at ten minutes before one, Nancy Howland popped her head in to ask Sarah and Doris if they would like something from the cafeteria. Doris begged off, raised a Tupperware container from her bag, and asked Nancy for directions to the nearest microwave. Sarah, though slim, never willingly skipped a meal. Skeptical about the quality of the cafeteria’s offerings, she answered that any vegetarian sandwich or wrap would be fine. As she started to reach for her wallet, Howland waved her off, saying it was on the house — and that she’d just brewed a new pot of coffee, which was welcome news for Sarah.

  By half past one, the two women had finished lunch. Right on time, the person Sarah was now most interested in arrived at the door. Albert Cappelli, the pharmacist who had filled the or
ders for the Arkin baby, was a pleasant-looking man in his sixties. Cappelli was balding, mustached and carrying an extra twenty pounds in the midsection of his sturdy frame. He smiled as he extended his hand to both Sarah and Doris. He seemed relaxed. Sarah wondered how he could be, knowing the reason for the interview. She thanked him for coming in and wasted no time in getting started. She nodded to Doris, started the recorder and gave her standard introduction before posing the first question to the kindly looking pharmacist.

  “Mr. Cappelli, how long have you worked at the hospital pharmacy?”

  “That’s a little complicated. I worked at this hospital’s pharmacy for twenty-seven years before I retired two years ago. But when I retired I told Joanne Marsh — she’s the head of the pharmacy — that I wouldn’t mind coming in to help out when they were short staffed. I figured it would help keep me in the game, as they say, and the extra money couldn’t hurt, either. So, to answer your question, I guess I’d say twenty-seven years full time and two years on and off.”

  “Could you give me an idea of how frequently you’re called back to help out in the pharmacy?”

  “Well, it goes in fits and spurts. Sometimes, nothing for a few weeks. Then, I can be called quite frequently. They’ve had a lot of pharmacists out lately due to some bug that’s going around. Luckily, it’s missed me so far. This month I’ve been in four times already, and it’s only November eleventh. So I would say it’s uneven.”

  Sarah’s mind started to race. How much did Cappelli know about the new BCMA computer system? There had to have been training for all of the staff. Were Cappelli and other substitute pharmacists included? She decided to pursue that point before getting to his version of the previous day’s events.

  “Mr. Cappelli, were you given training for using the new computerized medication system, the BCMA?”

  Cappelli smiled broadly, shaking his head gently up and down. “I guess you’d have to call me a twentieth-century kind of guy. I was a practicing pharmacist long before computers were part of the landscape. Yes, they gave me a little tutorial, I guess you would call it, when I came in last week. I’d been hearing about it for months and I read up on it at home.”

  Sarah persisted. “Did you attend any training sessions offered by the hospital before the BCMA was instituted?”

  “Well, here’s the thing. The full-time people were given time off from their regular duties to go to these sessions. The subs like me, well, if we came in for the training, there was no compensation offered. And to tell you the truth, it wasn’t so complicated that I had to sit for hours to learn how to use it.”

  Joanne Marsh’s demonstration had certainly made the system seem straightforward, so Sarah could see how an experienced pharmacist would think he could take a pass on formal instruction. However, yesterday’s medication error exposed how wrong he was. She decided to get a sense of the depth of Cappelli’s grasp of the system. Given her own limited understanding, she knew she was taking a chance, but she thought it was worth a question or two.

  “So help me — as a layperson — and explain how the new system works.”

  “No problem. It’s really very logical. The order comes into the pharmacy by computer. The patient’s medication profile pops up. We can see any interactions, contraindications, etc. If there are no problems with the medication profile, we get the medication from supply, scan it and the computer pops out a label. We put the label on and send it through the pneumatic tubes. Everything is bar coded and scanned. It’s just like in the grocery store. Before the meds are administered, the nurse scans the patient’s wristband to make sure everything is simpatico. Very nice. Helps to keep down medication mistakes.”

  Cappelli’s explanation jibed with the one she had gotten from the head pharmacist. He clearly understood the broad outlines of the program. But a terrible error had still occurred, and current evidence indicated Cappelli could have been involved. It was time to find out how.

  “Mr. Cappelli, I’d like you to recall the orders for the infant Ariel Arkin that came in late yesterday afternoon.”

  “Sure. I filled hundreds of orders yesterday, but I heard there was a problem with the baby, so I racked my brain to remember exactly what I did with those scripts.”

  “And what do you recall about filling the scripts for the infant?”

  “The first thing I remember is that the orders came in as a hurry call, so they went to the top of the list of orders to fill. There were two: clindamycin — that’s an antibiotic, often used for staph infections including MRSA, the drug-resistant kind of staph; and heparin for an IV flush every eight hours. Now this is new. We rarely were asked for heparin for most of my career. It was just stocked by pharmacy techs on each floor — near the patients. And I think it’s still done that way in most of the hospital. But the powers that be decided that, as a way to prevent incorrect dosing, heparin would no longer be kept in the neonatal and pediatric patient care areas. I guess this was in response to overdoses that occurred around the country over the years. Personally, I couldn’t recall an overdose in this hospital. Me, I figure why fix what’s not broken? But I learned long ago that my opinion is not required when they change policy around here. I just follow orders.”

  “Mr. Cappelli, how did you fill the orders for the Arkin baby?”

  “Well, just as I described. I got the clindamycin, scanned it, and the label popped out of the printer. The scanning system didn’t like the heparin order, though. It refused to print the label, so I just handwrote a label with the patient’s name, ID number, doctor, dose, etc.”

  “Do you remember the dose of the heparin?”

  “Sure, for a baby’s IV flush the doc would order a low dose — 10 units per milliliter.”

  “And did you fill the doctor’s order for that dose?”

  “Of course. I did what I’ve done hundreds of times before. I went to the shelf, got the blue-labeled heparin vial — blue is the 10-unit vial. Then I wrote out the label when there was a glitch in the computer system. I got a young tech, Alejandro — he’s new — and told him to run the two orders up to the peds floor ASAP, which he did. He was back in the pharmacy in less than five minutes. Mission accomplished.”

  “And what is Alejandro’s surname?”

  “Let me think.” His drummed his fingers on the table for a bit. “I think it’s Avila.”

  “Thank you,” Sarah said as she made a note to herself to have Alejandro Avila called in for an interview. “Mr. Cappelli, you said that you’ve filled orders for 10 units of heparin many times before.”

  “Yes, of course; after the heparin orders for peds and neonatal started coming through the pharmacy. It’s used all the time for IV and catheter flushes.”

  “And you mentioned that the label for 10 units is blue, is that correct?”

  “Yes, it’s blue and the heparin 10 is stored on the third shelf — in the front — of unit eighteen in the pharmacy. After so many years I know that pharmacy like the back of my hand.”

  “Mr. Cappelli, do any other heparin vials have a blue label?”

  The veteran pharmacist closed his eyes and thought for a moment. “Yes, 10,000 units also has a blue label — maybe a slightly different blue. But we store that on the top shelf at the back of unit nineteen. We use that full-dose heparin for anti-coagulation to prevent heart attacks, deep venous thrombosis and pulmonary embolisms.”

  “And you got the Arkin baby’s script from unit eighteen?”

  “Yes, just as I said.”

  “Well, Mr. Cappelli, the vial of heparin that was received on the floor was not 10 units. It was 10,000 units.”

  The pharmacist was clearly perplexed. “I don’t see how that can be.”

  “Would you like to see the vial that was used on the Arkin baby?”

  Concern crossed Cappelli’s face for the first time since he had entered the room. “You have it here?”

  “I can get it. Mr. Mess has it next door.”

  “Yes, I would like to see it, if that�
�s okay.”

  “Of course.” Sarah got up and excused herself. She wondered if Doris would engage the pharmacist in her usual chitchat while she retrieved the vial from the safe in John Mess’s office. When she returned, she found Doris reviewing her transcription and Cappelli looking at his hands.

  Sarah sat down and showed the pharmacist the vial in the plastic bag. He looked at the label with his handwriting. Then she turned the bag over to reveal the blue label with the clearly printed notation: Heparin, 10,000 USP units/mL. Cappelli took out a handkerchief from his back pocket, blew his nose and wiped his eyes. In no more than a whisper he said, “I’m sorry. I have no idea how this could have happened.”

  CHAPTER EIGHT

  It was a few minutes after two when Sarah and Albert Cappelli arrived at the pharmacy. In a matter of minutes it became clear what had happened to result in the Arkin baby getting a thousand times the heparin Dr. Smith had prescribed.

  The supply of heparin 10 was, just as Cappelli had said, stored in the front of the third shelf of unit eighteen, and the heparin 10,000 supply was stored on the top shelf of unit nineteen. Each location was clearly marked with a label and a bar code. However, behind the heparin 10 shelf label and next to a nearly empty box of 10-unit vials sat a new box of blue-labeled vials containing 10,000 units of heparin. Alejandro, the new pharmacy tech, had restocked the shelves yesterday. Sarah would have to interview him, but it seemed likely he had mistakenly put the look-alike 10,000-unit vials on the shelf where the 10-unit vials were supposed to go.

  Cappelli took a long, hard look at the incorrectly placed box and excused himself to use the restroom.

  As Sarah stood alone next to the shelf with the offending heparin, she surprised herself with the degree of sympathy she had for the people whose slip-ups had led to the catastrophic overdose. The veteran pharmacist had failed to catch the pharmacy tech’s error when filling the rush order. He seemed to put less stock in the new BCMA system than in his decades of experience in the pharmacy. A nursing pro stretched thin, working with a sick, crying infant and her distraught parents, had failed to notice the discrepancy between the printed and handwritten heparin labels. Surely fatigue would have to be considered a factor in her error.