A 23-year-old patient choked to death as Oregon State Hospital staff fumbled through emergency procedures, committing one error after another as the young woman lost consciousness and died, The Oregonian reported yesterday.
Nikolina Stoyanova died April 20, 2012, just over a month before her 24th birthday, at the Portland campus of the Oregon State Hospital, where she had been since November 2011.
Stoyanova had a documented history of self-harming behavior, including swallowing objects. That evening around 10 p.m., however, a contract nurse handed her a small bottle containing eye drops. Stoyanova popped it into her mouth and swallowed.
Staff members used the Heimlich maneuver to try to force the bottle out, and for a moment it did come back up, but Stoyanova swallowed it again and the bottle lodged in her airway.
The nursing supervisor called 9-1-1 from a back office. After providing initial information, the 9-1-1 dispatcher told her to call back from a phone closer to Stoyanova.
The supervisor tried to call back from a cordless phone, but could not make it work. As other staff members called for oxygen, she grabbed an oxygen tank and mask from a crash cart, but the tank was empty. She then tried to call 9-1-1 again, this time from a hospital cell phone, but mistakenly dialed “9” before the number.
Finally the supervisor managed to reach 9-1-1 from a staff member’s cell phone. By that time, an ambulance had already arrived, but at the wrong entrance. Staff members found the emergency crew and led them to Stoyanova, but it was too late to save her. Stoyanova was pronounced dead at 11:07 p.m. Her death was ruled a suicide.
Stoyanova was the victim of severe abuse by her adoptive parents, Justin Smith and Janis Kuchler of Pendleton. She won a $70,000 judgment against them in 2005. Over the last decade, she was in and out of care facilities, including the state hospitals in Salem and Portland.
Oregon State Hospital administrators said new procedures are being implemented to help prevent a similar situation from happening in the future. Changes include the following:
- Patient risk factors will be listed on daily sheets, not just in the medical chart
- Emergency equipment, such as oxygen tanks, will be checked daily
- When an ambulance is called, staff will go outside to meet rescue workers and direct them to the right entrance
- Staff will receive additional training on how to use phones
“We know we have the state’s most vulnerable and sick patients here, and the reason we’re in this work is to try to help them into recovery,” Dr. Rupert Goetz, the hospital’s chief medical officer, told The Oregonian. “What I really want to say most is how much of a tragedy this is and how much we want to use this as an opportunity to grow and improve our skills.”
Source: The Oregonian, June 30, 2012
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