Going to Plan T | Bob Norman | South Florida | Broward Palm Beach New Times | The Leading Independent News Source in Broward-Palm Beach, Florida

Going to Plan T

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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.

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Journalist Bob Norman has been raking the muck of South Florida for the past 25 years. His work has led to criminal cases against corrupt politicians, the ouster of bad judges from the bench, and has garnered dozens of state, regional, and national awards.
Contact: Bob Norman

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