Hospital apologizes for error in McClinton death
Ex-Juneau health, rights activist was mistakenly injected with highly toxic antiseptic solution
Mary McClinton, 69, of Everett, Wash., had the operation Nov. 4 at Virginia Mason Medical Center and died Tuesday after amputation and other extreme attempts to keep her alive, hospital quality chief Dr. Robert Caplan said.
"We're just so sorry and so devastated this happened," Caplan said late Tuesday. "It's a very unfortunate error that we all feel horrible about."
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He said the family is planning a Juneau memorial service for sometime in December.
"My mother was such as wonderful woman and she touched so many lives," he said.
Mary McClinton worked with the Tlingit and Haida tribes for many years and was inducted into a tribe as a member. She also worked for the Juneau Alliance for the Mentally Ill as a counselor, job coach and board member. She helped form the Coalition Against Racism and Discrimination to help fight discrimination in Juneau public schools and was a foster parent for several mentally handicapped Juneau children.
Gerald McClinton said his mother also was appointed to be on the state's Women's Commission by Gov. Walter Hickel.
Hospital officials have apologized for the fatal error, issued a detailed staff memorandum detailing what happened, retrained staff and changed procedures in an effort to prevent any similar mistakes.
In a statement posted on its Web site, the hospital said, "Recently, a preventable medical error occurred at Virginia Mason that we believe caused the death of one of our patients.
"We have offered our heartfelt apologies to the family of the patient and are doing everything we can to help them in this time of grief, but perhaps the only way we can make our apology real is to do everything we can to prevent medical errors in our system."
At the end of Mary McClinton's recent operation, a technician was supposed to inject a harmless marker dye used for X-rays into a leg artery. Instead, the syringe was filled with chlorhexidine, a toxic antiseptic used to clean the skin.
"The cleansing solution basically acted as a poison, which caused widespread damage to the organs of her body," Caplan said.
The damage "couldn't be remedied or reversed, even through aggressive treatment," he added.
Over the next two weeks the patient's health deteriorated as she underwent a leg amputation, and suffered a stroke and multiple organ failure leading to death.
Immediately after the operation "things were looking good, but in reality when that plunger was pushed, my mother's fate was sealed," Gerald McClinton told KING Television.
A hospital staff memo, issued on behalf of chief executive Gary Kaplan before McClinton died, said she had been the victim of "an avoidable mistake that caused massive chemical injury."
Quality chief Caplan said that "while no single person is responsible, all of us are responsible."
Everyone involved in the mistake was taken off duty and retrained, along with the entire medical staff, hospital officials said. The technician and others involved, who were not identified, are back at work.
A hospital investigation concluded the issue was not carelessness but a system that allowed two clear solutions to be confused.
Virginia Mason had recently switched from using a brown iodine antiseptic to a colorless version that was better at killing germs. The marker dye is also clear. The syringe was filled from an unlabeled cup containing the antiseptic.
Caplan said procedures have been changed to ensure that the two solutions are never put on the same table during a procedure.
The liquid antiseptic "now comes as a swab on a stick," making an accidental injection impossible, he said.
Steven McClinton, another of Mary McClinton's sons, called the hospital-wide memo "a very strong piece of paper written by a really wonderful doctor who feels just as strongly about this as we do."
Gerald McClinton said his mother had excellent staff and nurses to care for her, but the antiseptic shouldn't have been in the operating room. He also said the hospital had no choice but to apologize.
Family members reportedly have consulted a lawyer, but there was no indication that they planned to pursue legal action.
Asked if the family planned to sue, Caplan said, "That hasn't been the focus of our discussions."
"The hospital said they want to do the right thing," Gerald McClinton said. "What the family hopes is that we don't have to sue."
Juneau Empire reporters Timothy Inklebarger and Tony Carroll contributed to this article.
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