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| Somerset Medical Center |
A most astonishing case began after two people at Somerset Medical Center in Somerville, New Jersey were given the wrong medication. The ICU nurses who discovered this did not yet know that they were sharing in a disturbing experience with other healthcare workers in nearby institutions. They also did not know that their own institution was soon to be warned, and that SMC would break the case. All they knew was that one man had died and another woman had just barely been saved from an overdose of digoxin. Newspapers from the affected areas, the Newark Star Ledger and the Morning Call, along with national and other local publications, followed the story as it unfolded, with one of the Star-Ledger reporters leading the way.
The state-of-the-art computerized care system at SMC, called Cerner, allowed nurses to check patients' medical history at a terminal, according to Max Alexander, in the Reader's Digest. Another system tracked all drugs that were used and opened a drawer that allowed workers to get them. So the procedure for accessing and dispensing meds had become much easier.
On the night shift of June 15, 2003, someone ordered digoxin, a heart medication, for a patient, although it had not been prescribed and nothing in the patient's history indicated a need for it. Then it was canceled on the computer, but the drug itself disappeared from the stock. Around the same time, someone accessed the records of Jin Kyung Han, a forty-year-old cancer patient. She'd been battling the disease for a while, and the next morning she went into a cardiac seizure. When blood work was done, her doctor was surprised to find a high level of digoxin in her system. She'd been given this earlier but had been taken off when she reacted badly. An antidote was administered and she stabilized. But the drug's presence puzzled the staff.
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| Reverend Florian Gall |
Less than two weeks later, a sixty-eight-year-old Roman Catholic priest, Reverend Florian Gall, died. After the autopsy, high levels of digoxin were found in his system as well, but he was a heart patient, so the drug was not unexpected. Yet at that dose, it looked suspicious. Such levels seemed more sinister than could be dismissed as someone's error.
The hospital administration sent records and samples to the New Jersey poison control center and initiated an internal investigation. With their sophisticated computer system, they were able to see who might have taken digoxin from the system. It didn't take long to see the beginning of a pattern.
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