Going to Plan T
The North Broward Hospital District for years has tried to build a world-class heart surgery unit. What it never had was a heart.
The district, with its budget pushing $1 billion, was corrupt and cold, playing with tax dollars like it came from a Monopoly game. It hid its actions from the public while signing bloated contracts with cronies and making incredibly wasteful insider deals.
But that seems to be changing. The district is becoming almost self-conscious about changing its image, about opening its doors to scrutiny, about finally becoming accountable to the public that funds it.
It's actually getting downright touchy-feely and the change can be a bit unsettling, as it was last Friday afternoon. I was sitting in a sixth-floor conference room at NBHD headquarters chatting with Chief Executive Officer Alan Levine, Broward General Medical Center CEO Joe Scott, and a couple of senior vice presidents.
The reason for the visit wasn't a pleasant matter. It concerned a story I was writing about the outrageous death of a 44-year-old patient, a mother of three, who was administered a lethal medicinal overdose by a nurse at Broward General.
Just the fact that I was meeting with top brass was a little strange. Back in the day say, a year ago the district brass would have avoided me like dengue fever. Public records would stay put, locked in a room somewhere, withheld from view. Former CEO Wil Trower would have had his underlings give me the runaround. Former General Counsel Bill Scherer would simply trot away from me without a word, usually into an elevator.
Key word: former. That was the old district, the one that was in place before former Gov. Jeb Bush, responding to investigative reports published in New Times, radically overhauled the place, replacing all but one of the board members and sending Trower and Scherer packing.
New CEO Levine, handpicked by Bush to replace the ethically challenged Trower, greeted me Friday with a smile and a handshake and said, "Reading your stories has helped me learn what was happening around here."
Then, a little later, this sentence left the rather boyish-looking Levine's lips: "What happened with this patient was very tragic and it never should have happened."
At the old district, admitting a mistake was about as rare as telling the truth. It just didn't happen much certainly not in connection with its own mistakes. But Levine was definitely right: Michelene Woodin never should have died.
I already knew the basics about Woodin's death. The 44-year-old mother of three from Coral Springs had gone to Broward General's newly built, $163 million emergency room on April 23 to get a refill for Klonopin, a drug prescribed to treat her panic disorder.
That's all, just to get a prescription refilled. While at the hospital, she had a mild seizure. The physician on duty, Paul Rohart, ordered that Woodin be given 800 milligrams of the anticonvulsant Dilantin. Parceled out in 250 milligram bottles, the nurse should have given her a little more than three bottles through an IV.
But Woodin didn't get three bottles. Instead, the nurse, identified as Dionne Cooper, gave her 32: a massive and absolutely deadly overdose.
The patient never had a chance. When used therapeutically, levels of Dilantin, the brand name for phenytoin, should range from 10 to 20 micrograms per liter of blood. Anything above that is toxic. Woodin had more than 160 micrograms per liter of blood of the drug in her system, according to Broward County Medical Examiner's Office records.
Her husband, Randall, first alerted doctors that something seemed wrong. She was twitching in her bed. Soon, she died. Randall Woodin says he watched helplessly as she just... stopped.
"I had no clue what was happening," he says.
Nobody in the entire hospital seemed to know why Woodin died. Her ER physician, Rohart, slowly learned of the overdose only over the course of several weeks. When he was finally told how much Dilantin the nurse had given the patient, he says he was shocked.
"It was like giving her a whole bottle of aspirin for a headache," Rohart says. "She was given enough Dilantin to kill a lot of people."
Cooper never returned to work. Less than four months after the overdose, Rohart was notified that he was being fired without explanation by Phoenix Emergency Medicine, the private company that contracts with the district to provide ER doctors. The doctor, who has not been implicated in Woodin's death, has since filed a whistleblower suit in Broward Circuit Court against Phoenix.
The district quickly offered Randall Woodin a $200,000 settlement to keep the matter out of court. He accepted. That amount is the cap that the district, which has sovereign immunity because it is publicly funded, can pay out to a victim of malpractice without special approval by the Legislature.
Woodin's death is still under investigation by the state's Agency for Health Care Administration, agency spokeswoman Cristal Cole says.
And that's just about all I knew when I called the district for answers. District spokeswoman Trish Power first said she couldn't discuss the case for reasons of patient confidentiality. That sounded just like the old district.
Then she called and said Levine wanted to meet. It wasn't until I got there that I learned that, in addition to Levine, Broward General CEO Scott, Vice President of Marketing Joe Rogers, and the district's chief ethics officer, Spencer Levine, would also be there.
I didn't expect much. As far as I was concerned, it was just three more suits who would try to obfuscate the case and bring some positive spin to the district.
They proved me wrong. Scott told me critical details about Woodin's death that he really didn't need to share. He said the nurse made the mistake because she somehow mistook the 800 milligrams prescription for eight grams, which is ten times the safe dose. He said that he didn't know how she made that unfathomable error but that she had worked ten years at Miami's Jackson Memorial Hospital, where they didn't routinely use Dilantin. (Scott said it was his understanding that Cooper, whom I couldn't find, was working at another hospital in Broward County. Rohart said he had heard she had returned to her home country of Jamaica.)
To get the Dilantin, Cooper had to get the bottles from medication dispensers, called Pyxis machines, located throughout the ER. Each Pyxis holds only one or two doses of each drug. So she had to go to numerous dispensers to amass the 32 bottles, Scott told me.
Then Cooper went to Woodin's room and filled an entire IV bag with the Dilantin. There was so much, Scott told me, that she had to partially fill another bag.
Then she basically dumped it all into Woodin's bloodstream at a faster rate than even a normal dose should be given, the hospital's CEO said.
Scott said more than once that he doesn't know to this day why Cooper didn't realize she was doing something terribly wrong. There were so many red flags.
The nurse admitted her mistake the next day. Scott said she was fired not because she erred but because it was discovered she'd tried to hide the fact that she'd dispensed all that Dilantin from so many machines.
The hospital immediately put in safeguards to keep another nurse from ever being able to make the same baffling mistake again, the executives told me. Those Pyxis machines now hold only one vial of Dilantin each and a supervisor is alerted if a nurse tries to get them from more than one machine at a time. To get a full dose, the nurse must now go to the pharmacy, which provides documentation and another check on the health care workers.
The district notified the Florida Department of Health of Woodin's death within 15 days, as required by law. "It's very important for hospitals to disclose what has happened," Alan Levine told me. "The thing that can happen is a shroud of secrecy... because then it could happen again."
Hey, it's only words. But they are refreshing words to hear from an agency that operated in a "shroud of secrecy" for decades.
If the apparent open-arms policy is a media strategy, it was effective this time around. When I got up to leave the meeting, it seemed clear that a single nurse had made an unfathomable error. The district, while not perfect, handled it responsibly.
Maybe it got off cheap with the $200,000 settlement taking a woman's life at 44 seems like a much worse mistake to me, Legislature involvement or not but Randall Woodin told me he still believes it was fair. And are we supposed to get angry when district lawyers save taxpayers money on potential lawsuits? Just the opposite.
There's certainly a chance Dr. Rohart was wrongfully fired for his efforts to find out what happened. But that's a matter for Phoenix more than the district and more a matter for the courts than this column.
The district is doing more than opening up about a medical mistake that could damage its reputation. Just last week, the district's board voted to impose harsher ethics rules on itself. The new policy was drawn up by Spencer Levine (who is not related to Alan), the district's chief ethics officer.
Unlike the old officer, Spencer Levine is no low-level guy sitting in an out-of-the-way office. Levine, who used to run a major Medicare fraud unit for the state, is a senior vice president who answers directly to the CEO.
As I was leaving, Spencer Levine stepped closer to me and said that this new regime is nothing like the old one. "We are all about transparency," he said. "We will not hesitate to get you whatever you need whenever you need it."
"I guess we'll see," I said to him.
"Test us," he challenged.
It's a sure thing there will be more tests. The district, while it's definitely moving in the right direction, has too much politics and too much money in it not to have some conflicts lurking under the surface. Let's just hope the new brass will pass the test when those problems come to light.
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