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Twelve-year-old Tiffany walked with her mom into the suburban surgi-center, a satellite
out-patient facility, which was part of a much larger and well-known university
hospital system. Tiffany was having a routine T&A (tonsils and adenoids) that day.
She was nervous about the surgery but excited about the unlimited ice cream that
had been promised while she healed.
Tiffany’s surgeon, Dr. E, had suggested she perform the T&A at the surgi-center,
rather than the hospital, since this was a routine procedure and Tiffany was scheduled
to go home later that same day.
Everything unfolded as planned. Tiffany and her mom went straight from the admitting
desk to the pre-op area, where Tiffany changed into her patient gown. There, a pleasant
nurse asked a few questions, determined that Tiffany was the right patient, and
started an IV. Dr. E arrived, spoke briefly with Tiffany and her mom, and left
to scrub for the surgery.
Forty-five minutes later, Tiffany was wheeled out to the post-anesthesia care unit
(PACU), minus her tonsils and adenoids. Since she was beginning to regain consciousness
and moaning, the anesthesiologist, Dr. A, gave Tiffany a 50 microgram dose of Fentanyl,
through her IV line. Tiffany’s breathing quickly settled into a snore.
Dr. E walked into the waiting room and assured Tiffany’s mom that everything had
gone smoothly. She said that they would keep her for a couple of hours in the PACU
and then send her home.
Alice was a traveling nurse; she worked in different hospitals and different departments,
filling gaps in the schedule. Every few weeks she worked a shift in this surgi-center.
When Alice received her patient in the PACU, Tiffany was still snoring.
Alice read the orders on the chart. They included:
Fentanyl 50 – 100 micrograms IV every 3 – 4 hours or Demerol 25 – 50 mg IV, every
3 – 4 hours, as needed.
Alice didn't pay attention to the time of the last Fentanyl dose, nor to the "as
needed." She administered Fentanyl 50 micrograms through Tiffany’s IV.
Within three minutes, Tiffany stopped breathing. Alice didn’t notice because she
was busy adjusting the cardiac monitor. Two more minutes passed before Alice realized
something was wrong, and then another minute before she recognized that Tiffany
had stopped breathing. Alice screamed for a code and two other nurses rushed in.
One ran to get the surgi-center’s crash cart while the other tried to piece the
story together.
Dr. A arrived and assessed the situation quickly – opiate overdose. Dr. A knew
Tiffany needed two things: oxygen to feed her brain and Narcan to reverse the Fentanyl.
One of the nurses arrived with the crash cart and, in less than 90 seconds, Dr.
A intubated Tiffany and administered Narcan.
If only Alice hadn’t given the second dose of Fentanyl; the one that stopped Tiffany’s
breathing. Or, if only she had acted faster after Tiffany stopped breathing, she
wouldn’t have suffered severe brain injury; she would still be the bright pre-teenager
she was before the surgery.
Instead, Tiffany lives the life of a vegetable, with highly paid caretakers around
the clock. The jury awarded her family $12 million. Tiffany’s family settled – in
a high-low agreement – for $7.5 million.
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