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Hospital says error killed woman

An 18-year-old who had come to South Florida Baptist with labor pains received four times the ordered dosage of magnesium sulfate.

Published June 7, 2006

PLANT CITY — A pregnant woman died in South Florida Baptist Hospital two weeks ago because a nurse gave her an overdose of a common medicine, hospital officials said Wednesday.

Elisha Crews Bryant, 18, was seven months pregnant when she went to the hospital with early labor pains, family members said. A doctor ordered magnesium sulfate, a common treatment to slow early labor.

But the nurse who gave Bryant an IV bag of the drug mistakenly gave her too much, hospital officials said. She got 16 grams when she should have gotten 4, said the family’s attorney, Doug Burnetti.

Bryant began having trouble breathing.

“I knew something wasn’t right,” said Bryant’s husband, Preston Bryant, 21. “I tried to tell them, and they wouldn’t listen.”

Once they realized the mistake, doctors tried to save her but could not.

An overdose of magnesium sulfate can cause respiratory failure, low blood pressure and cardiac arrest.
The doctors delivered her son, Levi, by emergency caesarean section. He was in neonatal intensive care

Wednesday in a Tampa hospital.

“He’s amazing,” Preston Bryant said. “He’s fighting. … He’s doing excellent. At first he was having problems breathing, but now he’s breathing a lot better on his own.”

Hospital officials called a news conference to acknowledge the mistake after a spokesman for the family blanketed news media Wednesday with e-mails blaming the hospital for Elisha Bryant’s death and asking the public for money to help with medical and child care expenses.

Because of health care privacy laws, hospital officials wouldn’t name Bryant as the patient. But Bill Ulbricht, the hospital’s chief operating officer, made it clear that Bryant died because of a hospital nurse.

“Unfortunately, a team member mistakenly gave the patient more medication than was needed,” Ulbricht said. “Once again, we extend our sincere apologies to the family.”

The nurse is on administrative leave while the hospital continues to investigate. An Ob-Gyn nurse for about 20 years, she has worked for the hospital for about seven years and has been an “outstanding team member,” Ulbricht said.

He expects her to return to her job.

Ulbricht said the hospital has changed procedures to prevent the mistake from happening again. Extra supervision will be required when the drug is given, and changes have been made in the computerized drug-ordering system.

Hospital officials couldn’t say Wednesday why the nurse made the mistake.

It also wasn’t clear exactly how long it took for the overdose to be noticed and treated. Elisha Bryant went into the hospital about noon on May 26 and was dead by 3 p.m., Burnetti said.

Hospital staffers gave her calcium to reverse the overdose.

“The medical team made every effort to stabilize her,” Ulbricht said.

Both he and Burnetti said doctors told family members of the mistake immediately.

“Throughout this incident, we were in close communication with the family, keeping them informed, apologizing and expressing our sympathy,” Ulbricht said.

For the family, who live in Plant City, it was a horrific end to what they thought would be a joyous event. The couple was overjoyed when they learned their second child was a boy, Preston Bryant said.

“We were just ecstatic,” he said. “We got what we wanted.”

He got the call at his construction job that his wife was in labor. Even though it was two months early, he wasn’t worried. He was so excited that he forgot to clock out.

“When I got there, she was explaining to me what they were going to do,” Bryant said. “Within 10 minutes, everything was wrong.”

Tears stopped Bryant several times as he spoke. The couple’s 2-year-old daughter, Tailor , climbed in and out of his lap. At one point, she stretched her arms forward and cried out one word: “Mommy!”

Tailor still doesn’t know.

Her father doesn’t know how to tell her. Neither does anybody else.

“She thinks her mom is still in the hospital,” said Sherry Crews, Elisha’s mother. “I don’t think we even know what’s going through our minds. It’s like we’re living in a bubble.”

Burnetti is investigating a possible malpractice lawsuit. Ulbricht said the hospital has offered to pay all medical bills, but Burnetti said he hasn’t heard such an offer.

Asking the public for financial help was a family friend’s idea, Burnetti said. The hospital planned to announce the death once its investigation was complete, but it called the news conference when the family went public, Ulbricht said.

The hospital has reported the death to the state Agency for Health Care Administration, as required by law, Ulbricht said.

“We want our community assured this was a one-time incident,” he said. “This is a good place to come for health care.”

Preston Bryant used to think so. Tailor was born at South Florida Baptist.

“We had too much faith in them,” he said.

Now, his wife is dead because of something that “should never have happened,” he said. She won’t be there to do the one thing she wanted to do most: raise their children.

While Elisha never planned to become pregnant so young, she never looked back, her mother said. She dropped out of high school, eventually getting a job in a YMCA nursery so she could bring in some money but keep Tailor with her.

“She was one of the best little mothers in the world,” Crews said. “She took the role on, and she never regretted it.”
Preston Bryant feels lost.

“I can’t do it without her,” he said. “She was raising my daughter. I wanted her to raise my son.”

[Last modified June 7, 2006, 23:43:51]

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