An orthopedic surgeon with Madison, Wis.-based UW Health has been sanctioned after a patient died during shoulder surgery, according to the state medical board.
Molly Day, MD, will have to take six total hours of education in effective communications and root cause analysis, according to a Dec. 21 medical board order.
A patient was scheduled for a shoulder arthroscopy with her on Oct. 11, 2021, according to the order. During a preoperative meeting, a nurse asked if epinephrine, a drug used to control blood loss, should be prepared "in the bag or on the field."
Dr. Day said "either" and pointed to a 30 mL vial, thinking a smaller amount could be drawn from it and mixed with local anesthesia, according to the order. She did not specify the amount of epinephrine to mix with Marcaine, the local anesthesia.
A scrub technician then drew all the epinephrine into a syringe, the order said. The technician said she labeled the syringe "epi," but Dr. Day said it was not marked. Two other orthopedic surgeons said in sworn statements that in the past, syringes have been inconsistently labeled.
Dr. Day began the surgery without verifying the syringe's contents and injected the patient. The patient quickly developed an "abnormal heart rhythm," coded and died, according to the order.
A spokesperson for UW Health told The Wisconsin State Journal in a Jan. 9 report that Dr. Day is pursuing the required education and the nurse and scrub technician involved are employed at the health system. UW Health told Becker's in a Jan. 9 email, "Dr. Day remains a valued member of our faculty and we are confident in the treatment she provides to our patients."