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Power failed during open heart surgery at UNMH

Copyright © 2014 Albuquerque Journal

The power to Operating Room No. 2 went out more than an hour into Kathleen Williams’ coronary bypass surgery, just after the surgeon opened up her chest.

Kathleen Williams died on Aug. 11, 2011, four days after the power failed during her open heart surgery at UNMH

Kathleen Williams died on Aug. 11, 2011, four days after the power failed during her open heart surgery at UNMH.

The four lights above the operating table where she lay went dark. An equipment tower to harvest a vein in her leg stopped working. So did monitors, and suction and cautherization machines.

A balloon pump to aid blood flow went onto battery power. But, according to an operative report, no backup generator kicked in and the electricity remained off in the room for a “full 10 minutes” that morning of Aug. 11, 2011, at University of New Mexico Hospital.

Even though the power was restored, the surgical team, citing “patient safety reasons,” aborted the procedure and closed her incisions.

Four days later, Williams was dead.

UNMH records showed her death was the result of “cardiogenic shock with multi-organ failure secondary to her surgery,” said Albuquerque attorney Lisa Curtis.

“She had many horrible complications because they could not close her chest because of the power failure. This is beside the fact that she actually needed the bypass surgery,” Curtis said last week.

Williams’ family, in a wrongful death lawsuit filed last August, contends UNMH was medically negligent and displayed “wanton disregard for the safety of its patients.”

“Failure to maintain the systems that are critical for the functioning of the operating rooms at UNMH is a breach of the standard of care,” states the lawsuit filed by Curtis.

UNMH officials deny the allegations.

UNMH spokesman Billy Sparks told the Journal there was never a total power outage, but an “interruption” that involved “only one circuit breaker.”

Such an interruption wouldn’t activate a generator “and no generator or emergency system was activated,” said Sparks.

No other outages occurred, he added.

UNMH blames the loss of power that day on an electrical system upgrade that was completed in 2009, according to court documents.

More than $68,474 has been spent to “address the conditions that led to the interruption in electrical service to OR #2,” Sparks said in an email.

In March, UNMH and the University of New Mexico Board of Regents sued three contractors who worked on the electrical upgrade, alleging breach of contract and negligence.

The legal action came more than two years after the power failure and seven months after the Williams family brought its wrongful death case.

The companies being sued are Jack B. Henderson Construction, Fanning Bard Tatum Architects and The Response Group. Their attorneys in court records deny the allegations of defective design and/or defective work.

Before Williams’ operation, a UNM surgeon estimated her mortality risk from the coronary bypass surgery was “4.8 percent,” the lawsuit states.

Williams, 62, was married, and the mother of a son and daughter who are “mentally incapacitated,” according to the lawsuit. Surgery was recommended after tests showed left main coronary artery disease.

The lawsuit blames the outage for her death. It doesn’t name any of the surgical team as defendants, nor any of the companies now being sued by UNMH.

The university in its answer to the lawsuit lists 12 different defenses, including that the Williams family’s damages are a result of “independent, intervening causes unrelated to any act of omission on the part of these Defendants.”

No trial date has been set.

In a March 2013 letter to UNMH CEO Stephen McKernan, Curtis wrote, “There is an enormous violation of the public trust and the taxpayers’ investment to have this condition exist at all.”

Sparks told the Journal recently that there wasn’t a “true” power outage on Aug. 11, 2011, because the electrical power to the operating room was “never fully lost.”

A technician in the operating room that day alerted UNMH facilities staff who determined a circuit breaker on the roof had tripped a switch, he told the Journal.

“The switch was re-set and complete power was restored within less than 10 minutes,” Sparks’ email stated.

Williams’ operative report states, however, that “it was determined that there could not be 100 percent assurance that the problem would not occur again.”

That’s why the surgical team decided to stop the operation.

A report filed by UNMH facilities manager Rodney Roybal that same day stated, “Did check for obvious problems that could have caused the breaker, all we found was a cumulative overload of the primary breaker on the roof.” Sparks said 18,747 operations were performed at UNM Hospital in fiscal year 2012-13. “Patient safety is our top priority,” he added.

Sparks also noted that Presbyterian Hospital in Albuquerque experienced its own power outage last year and transferred three patients previously scheduled for surgery to UNMH.

When the Downtown Presbyterian Hospital lost electricity last Aug. 31, a Presbyterian surgical team was in the process of closing a patient’s incision in its operating room, said Sandra Podley, Presbyterian Hospital administrator.

“This was successfully completed with battery-powered emergency lighting, and the patient was discharged and reported no complications,” she told the Journal.

When the power failed, emergency generators at Presbyterian started immediately. Several, but not all, automatic transfer switches transferred as expected, she said.

“But a small, low voltage control fuse that communicates with the transfer switches then malfunctioned and the remaining switches were not provided the signal to make the transfer to emergency power,” she added. Maintenance staff had to transfer the switches manually.

“All emergency power was functional and fully delivered to the hospital within two hours of the initial failure,” Podley said.

Both Presbyterian and University Hospital are accredited by The Joint Commission, formerly known as The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Preventing adverse events caused by electrical power system failure is one of its goals, according to the website of the organization, which accredits and certifies more than 20,500 health care organizations and programs in the United States.

The commission recommends hospitals voluntarily report adverse events related to electric outages.

UNMH didn’t make a report. That’s because the hospital wasn’t required to do so, Sparks said.

Presbyterian did notify the commission about its August 2013 power outage, Podley said.

Presbyterian’s director of engineering met with commission officials “to discuss the incident and to explain mitigation plans to correct or replace elements of infrastructure that had failed during the incident,” Podley said.

Katie Looze, a media relations specialist with The Joint Commission, told the Journal that a power outage that results in death or serious physical or psychological injury, or the risk thereof, is considered a “sentinel event” by commission.

“When a sentinel event occurs, the organization (hospital) is expected to complete a root cause analysis, make improvements to reduce risk, and monitor the effectiveness of those improvements,” Looze told the Journal in an email.

Such analysis is expected to “reduce the likelihood of a failure in the future and to protect patients from harm when a failure does occur,” she stated. “In an effort to help organizations through this process, we have established a Sentinel Event Hotline.”

Looze said The Joint Commission wasn’t aware of the 2011 power failure at a UNM Hospital operating room until contacted by the Journal.

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