how mistakes were used in healthcare and pharmaceutical industries to drive innovation
Sumaikah Khan 17/07/2020
A tragic fate
Sorrel King and her family had recently moved to a new home. Sorrel’s mother had come all the way from Virginia to see their new house. The family were having dinner while their youngest, Josie, an eighteen-month old infant was playing a song from Barney on her music cube. Through the chatter with her family Sorrel became aware that the Barney music had stopped. She looked around for Josie but she was out of sight.
Sorrel began to grow concerned.
Just as they began to search for Josie, her screams could be heard from upstairs. Sorrel frantically ran upstairs and found Josie in the upstairs bathtub with second degree burns all over her body. Josie had tuned the H tap on, which meant that water had hit her skin near boiling temperature.
Little Josie was rushed to Johns Hopkins Pediatric ICU. The doctors’ first priority was to give intravenous fluids to her as second-degree burns impair the skin’s ability to control fluid and temperature. They cause high blood pressure and also are more painful than third-degree burns because second-degree burns don’t penetrate deep enough to destroy the nerve roots, so the patient can very much feel the pain.
A few days later the doctors removed the IV tubes from her body and replaced it with a central line catheter* and she was being monitored closely by the professional staff. Eventually, Josie’s condition began to improve, she could breathe without her breathing tube and she was able to eat again. Sorrel was immensely thankful to the doctors and nurses for taking such good care of Josie before things started to go terribly wrong gain.
Josie had developed an infection from the central line catheter. The doctors started to give her oral antibiotics, where giving antibiotics intravenously would have been more appropriate. But as her scarring from burns made it difficult to establish an IV line, and because the doctors were convinced that Josie was to go home soon, the oral antibiotics continued. Josie continued to vomit and developed diarrhea which further removed the fluids in her body, leaving her severely dehydrated.
Josie died shortly after.
Even though it looked like Josie’s heart stopped because of the methadone painkiller she had been receiving, it was clear that she died because of a medical error. While some of the nurses had suspected that placing an IV line would be more appropriate and tried to communicate with the surgeons, their concerns were disregarded. Due to the vast number of patients doctors are responsible for, they must rely heavily on numbers and charts to judge a patient’s condition, but alas, sometimes numbers can be deceiving. In contrast, nurses spend more time with the patient thus have a comprehensive understanding about their condition. This represents failure in the way hospitals used to operate, the nurses' concerns were not taken seriously, medical errors and court claims made against them brushed under the carpet and never looked at or anaylsed again, resulting the the same mistakes resurfacing later. Therefore, Josie had to pay the price for the severely hierarchal environment of the healthcare system, where often miscommunication leads to many preventable deaths.(Vohr E., 2010)
Taste of raspberries, taste of death(Ballentine, 1981)
In 1935 a German pathologist used a red dye called Prontisil to derive a drug called sulfanilamide. Sulfanilamides are sulfur containing compounds shown to kill (streptococcal) bacteria by inhibiting folic acid production. After hitting the market shelves, sulfanilamide quickly gained popularity as the first successful therapy for most bacterial diseases(Science History Institute, 2017). Penicillin had already been discovered six years earlier, but it was not widely accessible at that time.
After the patent for the drug expired, anybody could synthesise and sell variants of it. S. E. Massengill, a pharmaceutical company realised that there was a demand for the drug in the southern states in its liquid form. The company’s chief chemist and pharmacist, Cole Watkins found that the drug dissolved in diethylene glycol, a solvent. Once they added raspberries and caramel flavouring to it, it will make a nice cough syrup. Thus the mixture was tested for appearance, and fragrance, found it to be okay, and distributed it to several states. However, the drug had not been tested for toxicity, because safety testing on new drugs was not an obligatory step in drug manufacture. As long as you were selling what was on your label, it was compliant with the law. Selling toxic drugs was obviously harmful for a for business, but it was not illegal.
Diethylene glycol is a poison.
Over a hundred people died from its use. The instruction leaflet that came with the ‘elixir’ was to keep giving it to the patient until their condition improved. This meant that people unknowingly kept giving poison to their sick loved ones.
If only Massengill had tested it on some mice before shipping to various states, it would have saved lives. Maessngill was charged with an unprecedented fine by the Food and Drug Administration (FDA) because the product was mislabelled as an elixir, however, it needed a chemical called ethyl alcohol for it to identify as one.
Turning things around
As we saw in the above two anecdotes, things tend to go wrong, even with massive and important industries. Us as individuals may use failure as a measurement of how accomplished we consider ourselves in our lives. After all, isn’t it a reminder of the human fallibility? Or a barrier between the present and your aspirations?
Not for Sorrel King. As she transformed the loss of her daughter into a global movement of patient safety and patient advocacy (Mitchell, 2020). Sorrel King founded the Josie King Foundation and donated money to Johns Hopkins for patient safety programs. “She held us accountable,” Pronovost, the author of the book ‘Safe patients smart hospitals’ says of Sorrel. “She didn’t want what happened to Josie to happen to anybody else.”(Broadhead, 2016) Now, the Josie King Foundation holds events and provides resources to both caregivers and patients alike to prevent loss of life from medical errors.
As for the elixir sulfanilamide case, a new law was passed in 1938, giving the FDA increased power over drug safety. That law is given the credit to the prevention of the exacerbation of the effects of the thalidomide disaster in 1961.
In the examples King and the FDA, they used failure as a stepping stone towards a better future. Which, I think when implemented at a smaller scale, such as how we face failure, rejection and disappointment in our personal lives, could have drastic effects. So the next time you think you have failed at something, be proactive about getting feedback, digging deeper, setting standards and using that work ethic to thrive.
Glossary*
central line catheter: a tube that goes into a vein in the arm and runs all the way to the large vein near your heart
Bibliography
Ballentine, C. (1981). Sulfanilomide Disaster . FDA Consumer Magazine .
Broadhead, K. N. (1, 6 2016). An End to Error. Retrieved from Hopkins Medicine : https://www.hopkinsmedicine.org/news/publications/hopkins_medicine
Institute, S. H. (2017, 12 4). Historical Biographies . Retrieved from Science History Institute : https://www.sciencehistory.org/historical-profile/gerhard-domagk
Mitchell, E. (2020, 12 2). Professional Profile: Sorrel King, Josie King Foundation. Retrieved from EOS: http://blog.eoscu.com/blog/professional-profile-sorrel-king-josie-king-foundation
Vohr E., P. P. (2010). Safe patients smart hospitals.
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