Lab Error May Be Responsible for Two Patient Deaths


PHILADELPHIA, Pa-A laboratory worker's miscalculation may be responsible for the death of two hospital patients at St. Agnes Medical Center south of Philadelphia. There are 932 patients who were given miscalculated prescriptions because of the laboratory error.

Between June 4 and July 25, the dosage of Coumadin may have been incorrect because a laboratory worker reportedly misunderstood what type of chemical was being used. Coumadin is a blood-thinning drug patients are usually prescribed if they are at risk for a heart attack, stroke, or blood clots.

The hospital is releasing little information about the victims except that they were in their mid-80s to mid-90s. There are 58 patients were endangered or being retested because of the mistake. The miscalculation made it appear the patients' drug was clotting and they were in turn given higher doses of Coumadin.

The mistake was discovered after a patient contacted a physician about unusual lab results. Health authorities began notifying patients and physicians immediately after the error was uncovered.

Department of Health officials are continuing the investigation.

Information from

Related Videos
Association for the Health Care Environment (Logo used with permission)
Woman lying in hospital bed (Adobe Stock, unknown)
Photo of a model operating room. (Photo courtesy of Indigo-Clean and Kenall Manufacturing)
Washington, USA, US Treasury Department and Inspector General Office.    (Adobe Stock File 210945332 by Brian_Kinney)
A plasmid is a small circular DNA molecule found in bacteria and some other microscopic organisms. (Adobe Stock 522876298 by Love Employee)
Peter B. Graves, BSN, RN, CNOR, independent perioperative, consultant, speaker, and writer, Clinical Solution, LLC, Corinth, Texas; Maureen P. Spencer, M.Ed, BSN, RN, CIC, FAPIC, infection preventionist consultant, Infection Preventionist Consultants, Halifax, Massachusetts; Lena Camperlengo, DrPH, MPH, RN, Senior Director, Premier, Inc, Ocala, Florida.
Maddison B. Stone, MPH, CIC, LSSGB, senior infection preventionist, JPS Health Network, Fort Worth, Texas; and Jordan M. Chiasson, PharmD, BCIDP, clinical pharmacist - antimicrobial stewardship, JPS Health Network, Fort Worth, Texas
Central line catheter (Adobe Stock, unknown)
UV-C Robots by OhmniLabs.  (Photo from OhmniLabs website.)
Surgery (Adobe Stock, unknown)
Related Content