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“Your Hospital’s Deadly Secret,” Conde Nast Portfolio

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I. The Birth of Baby Alyssa

The light of their lives was born 12 inches long. She weighed just one pound four ounces. Her skin fit like a baggy suit. But from the moment Baby Alyssa arrived 14 weeks early, she was the biggest thing in the Shinn family’s world. Day and night, they were at her Isolette in the neonatal-intensive-care unit. They took videos that show a happy family basking in its joy and good luck. Richard, in his Dallas Cowboys jersey, strokes Alyssa’s tiny hand, no bigger than his thumbnail. In the background, Kathleen’s laughing voice can be heard, urging her daughter to open her eyes.

As days turned to weeks, the Shinns became optimistic. Despite Alyssa’s tiny size, she had none of the most worrying neonatal deficits—no bleeding in the brain or skin problems or blood vessels that wouldn’t close. She was gaining weight. At three weeks, the doctors took out her breathing tube. She was able to breathe on her own.

That was November 8, 2006. “I called her name, and she opened her eyes and looked right at me. She knew me,” Kathleen recalls. “It was the most comforting sensation I’ve ever had. It’s really almost indescribable, the recognition.”

Kathleen, 36 at the time, was well aware of the risks her daughter faced. She had worked as a nurse in cardiac, oncology, and intensive-care units. Five years earlier, she and her husband had relocated from New Jersey to Las Vegas, where she worked as the nursing supervisor at Southern Hills Hospital & Medical Center and served on its medication-safety team.

The couple had spent three years trying for a baby before the fertility treatments finally worked. Kathleen was so nauseous during pregnancy that she lost 25 pounds. After she developed hypertension, her doctor admitted her to Summerlin Hospital Medical Center, just five minutes from her home, because it has one of only four neonatal-intensive-care units in the area. More life-threatening complications led doctors to perform an emergency C-section at only 24 weeks.

Health care was the family profession. Richard worked in medical records. His mother worked at Summerlin on the housekeeping staff. Kathleen’s mother, Carol Schiavo, had worked in home health care. They’d weathered her stepcousin Michael’s battle to let his wife, Terry Schiavo, die after she’d lapsed into a persistent vegetative state, a family crisis that morphed into a national ordeal. The fact that Alyssa was alive had led Kathleen to return to church for the first time in 15 years.

The day that Alyssa began to breathe on her own, Carol, who had been by her daughter’s side since the birth, flew home to Tampa, Florida, to resume packing and close on her house. Now retired, she was moving to Nevada to be with Alyssa while Kathleen returned to work. “We were all sky-high,” Carol recalls. “This was a miracle baby.” Alyssa was also the only baby Kathleen would ever have, as doctors believed another pregnancy might kill her.

Kathleen left the hospital that night at around 11:30. Shortly after 3 a.m., she awoke to pump breast milk and called Summerlin. A nurse told her that Alyssa was a little short of breath. At 6:15 a.m., Kathleen called again but was told the nurses were in a shift change. Two hours later, a nurse said that Alyssa was a little “tired” but “okay” and would have her breathing tube reinserted, which was routine. At around 9 a.m., Kathleen and Richard were nearing the hospital for one of their twice-daily visits when Alyssa’s doctor called, wanting to know when they’d be in. Was there a problem? Kathleen asked.

“No,” he said. “I’ll talk to you when you get here.”

As they approached Alyssa’s Isolette, Kathleen’s heart fell. She saw a woman in a suit—the director of risk management—amid a knot of doctors. Alyssa was chalk white. Her doctor said there had been a problem with the baby’s T.P.N. bag, which contains the drip solution of total parenteral nutrition used to feed neonates. She had gotten too much zinc, and her heart rate was plunging. Kathleen began to cry.

Could they use dialysis to purge the zinc? she asked. Could they give her anything to offset the heavy metals? Was she going to die? The doctors didn’t know.

It would take months for her to learn the truth: that metastasizing problems of turnover and training lapses had left the Summerlin Hospital pharmacy in disarray. For years, Universal Health Services, the for-profit health-management company that owns Summerlin, had outsourced its pharmacy to a series of drug-distribution companies, which, taken together, buy and sell 90 percent of the country’s medicine. For these companies, managing hospital pharmacies came as an add-on to their core business of selling drugs, a response to pressure for profit in the distribution business. The management of the pharmacy—and U.H.S.’s oversight of its contractor—would later prove fateful to Alyssa Shinn. ( See how the giants that run U.S. pharmacies stack up. )

II. The Hospital Chain: Universal Health Services

Twenty minutes from the Las Vegas Strip, you can see for-profit health care at its most feverish. Turn in any direction and a hospital is being built. At Summerlin, which Kathleen drives by almost every day, a new $100 million tower will add 140 hospital beds. U.H.S., which operates Summerlin and three other Las Vegas-area hospitals, opened a fifth hospital in January. All told, five new hospitals have gone up in and around the city during the past two years.

For U.H.S., a $2.6 billion company and the nation’s third-largest hospital manager, Southern Nevada serves as a model for its core business goal: “to build or purchase health-care properties in rapidly growing markets and create a strong presence based on exceptional service and cost control,” according to its website.

As rivals like HCA, HealthSouth, and Tenet Healthcare have been hit with government investigations for fraudulent billing and accounting, U.H.S. has burnished its reputation as the humble hospital chain. “We don’t do any funny stuff with our numbers,” C.E.O. Alan Miller said in a 2003 BusinessWeek article. “We grow the old-fashioned way, through hard work and modest acquisitions.” For years, U.H.S. has been the only for-profit hospital chain with an investment-grade rating from Standard & Poor’s.

But U.H.S. has not entirely escaped scrutiny. In several states, regulators have uncovered severe understaffing and excessive use of restraints and seclusion for elderly and mentally ill patients at U.H.S. hospitals, and ongoing lawsuits allege that the company has overcharged patients with no insurance. The company, in filings with the Securities and Exchange Commission, has disclosed that an investigation into billing practices at its Texas facilities is also ongoing. And in 2002, an investigation by the U.S. Attorney’s office found that 91 patients at a Pennsylvania hospital acquired by U.H.S. had been improperly restrained over a six-month period, leading to the death of an Alzheimer’s patient who was suffocated by her restraint vest after she fell out of bed. The government alleged that even though U.H.S. had promised to limit its use of restraints six months prior to the incident, it had not. After a protracted dispute, U.H.S. agreed to pay $200,000 for the violations and review its policies. The Philadelphia Inquirer quoted a U.H.S. lawyer who stated that the death had occurred during a “transitional period of ownership” seven months after the company had purchased the hospital. Through a spokesperson, U.H.S. declined Condé Nast Portfolio‘s repeated requests for interviews. The company also declined to respond to questions submitted in writing.

But the Pennsylvania incident—and the company’s claim that it stemmed from turnover—struck a theme that would resurface four years later in response to the Alyssa Shinn case and to questions about how effectively U.H.S. supervised a revolving door of pharmacy managers at Summerlin.

U.H.S. is hardly alone in outsourcing vital patient-care services. With the increasing corporatization of medical care, hospitals have outsourced everything from emergency-room treatment and radiology to infection control. But every transition of vendors, every change in hands, multiplies risk, says James Unland, president of the Chicago consulting company Health Capital Group. “When something as crucial as a pharmacy company changes, it’s not just some people in the basement of the hospital,” Unland says. “It has an effect of permeating the entire organization.”

III. The Pharmacist: Pam Goff

When Pam Goff left Walgreens to work at the Summerlin Hospital pharmacy in February 2006, she had never encountered anything like it. The pace was frenetic, the procedures sloppy, and the turnover staggering, she says.

Goff, 31, does not seem like a typical pharmacist. She sports colorful tattoos, and her cell-phone ringtone is her favorite Pink tune. But she has a pharmacist’s DNA. She’s hardworking, high-strung, and meticulous, with a deep sense of personal responsibility, having clawed her way out of poverty with an ethic that has kept her working since age 14.

At Walgreens, Goff says, the training meant that new arrivals shadowed veteran pharmacists for a week before filling their first prescriptions. At Summerlin, the pharmacy director was commuting between Pennsylvania and Nevada. There was no formal training. Goff reasoned that the job as lead clinical pharmacist, however difficult, was a stepping-stone to her ultimate goal: specializing in pediatric pharmacy. It also offered more flexible hours, as she was caring for a toddler and working toward a doctorate in pharmacy.

Though Goff worked at the Summerlin pharmacy, she was not employed by the hospital. She had been hired by the giant health-care-services company McKesson Corp., headquartered in San Francisco, which ran the pharmacy for U.H.S. and was technically its owner. McKesson was the third company to manage Summerlin’s pharmacy in a decade. Before that, Cardinal Health had been in charge, replaced at the end of its contract when McKesson offered better terms to U.H.S.  Between 2000 and 2006, six pharmacy directors had come and gone. There was so much “interbreeding,” Goff says, that you never knew who had been hired by which company or trained under what protocol.

More than 8 percent of the nation’s 5,500 hospitals outsource the management of their pharmacies to companies like McKesson. These companies can seem like a godsend for hospital C.E.O.’s facing soaring pharmaceutical costs and a nationwide shortage of pharmacists. McKesson and Cardinal Health, which are two of the largest, promise to do it all: staff the pharmacies, set up inventory-management systems that can increase efficiency and safety, and be a one-stop shop for drugs, all at a reduced price.

But a fundamental problem exists, says Kurt Patton, former executive director of hospital-accreditation services for the Joint Commission, an independent oversight agency that inspects and certifies hospitals. Hospitals that turn over their pharmacies to management companies often cede nearly total control. This can create a dangerous disconnect between the hospital’s medical staff and the pharmacy.

At the nurses stations, according to Goff, bags of saline, some with potassium and some without, were jumbled together in the same bins, without separate color coding—a practice frowned on by the Joint Commission, since a mix-up can be lethal. The nurses kept supplies of long-acting insulin on the floor, whereas the Joint Commission recommends only regular insulin as floor stock. The long-acting kind requires a special pharmacy order, because its accidental use can induce diabetic shock.

In the fall of 2006, the Summerlin pharmacy appeared to take a leap forward when a highly sensitive compounder known as a Baxa machine arrived, replacing an outmoded one. The new machine could mix medicine in amounts smaller than humans can accurately measure, reducing the chances for error in making T.P.N. bags for babies. But the policies at Summerlin for making the bags were not updated accordingly. They had not been changed since 2003, a year before the hospital opened its high-level NICU.

In almost any pharmacy, the policy-and-procedure manual serves as the pharmacists’ bible. But the Summerlin manual had not been changed to reflect the new policies, as pharmacist Jackson Yu would testify before the Nevada State Board of Pharmacy, “because we had gone through so many directors. They would take on a task but never stay long enough for it to come to fruition.” Goff found two separate procedure manuals floating around, both outdated and containing conflicting information.

Goff was also disturbed to find that her staff included a technician named Asia Cornelius, whom she says she had fired from Walgreens for inattentiveness and poor math skills. McKesson had not checked her most recent reference—Goff—and ignored Goff’s complaints about her performance at Walgreens. Cornelius’ lawyer could not be reached for comment.

Despite her concerns, Goff decided to stay on at Summerlin, in part because the pharmacy was in transition and she hoped for improvement. In July, when McKesson’s contract ended, U.H.S. brought in a competing company, AmerisourceBergen, the fourth in a decade, to advise it on how to run its hospital pharmacies. The new interim manager under AmerisourceBergen, Gretta Woodington, was the sixth pharmacy manager in six years. On the evening of November 8, Woodington chewed out Goff for a range of offenses, from corresponding with the hospital management, allegedly behind her back (she’d forgotten that she’d asked Goff to do so), to not translating the prescriptions for neonatal T.P.N. as everyone else did. Goff, who was told to work the late shift because of short staffing, challenged Woodington. She explained that ever since the doctors had replaced dietitians in writing T.P.N. prescriptions, they had used widely varying formats. Some specified the amount of ingredients by weight of the baby in kilograms, others by volume of the bag in deciliters.

The Joint Commission, as well as the American Society for Parenteral and Enteral Nutrition, recommends that hospitals use only one format, ideally one that’s standardized, to prevent confusion and mistakes. The preferred method is by the weight of the baby, and the Baxa machine was programmed to format the amount of ingredients that way. So Goff calculated every prescription, regardless of how it was written, by weight of the baby.

But Woodington was in no mood for debate. She threatened that unless Goff translated the prescriptions the way the doctors had written them, she would put a note in her personnel file. The exchange left Goff in tears.

That night, two T.P.N. orders came down from the neonatal unit, and they were late. Orders are supposed to arrive by 5 p.m. and be completed by 7, so that potentially hazardous, high-alert medicine won’t be prepared by a skeletal staff.

The one for Alyssa was written the more dangerous way, in Goff’s view. It called for 330 micrograms of zinc per 100 milliliters of fluid. She worked out the prescription the way she usually did—first calculating the bag’s total volume and then calculating the amount of zinc per kilogram of Alyssa’s weight, a number written at the top of the prescription. Uneasy, she stared at the numbers for some time and then, mindful of Woodington’s reprimand, went back to the drop-down menu to select the zinc format as micrograms per deciliter of fluid, the way the doctor had written it.

Goff’s labels had initially been correct. But when she went back, she accidentally selected milligrams, not micrograms, of zinc per deciliter from the machine’s drop-down menu. She then passed the printed labels to a verifying pharmacist, whose job was to ensure their accuracy, and “never saw them again,” she says. That night, Goff’s labels went to Asia Cornelius, who was filling in for a sick technician. Though testimony would later reveal that Cornelius’ work at Summerlin had been riddled with errors, she was assigned the job of filling Alyssa’s prescription at the Baxa machine, the pharmacy’s newest and most sensitive piece of equipment.

The Baxa’s software contains a crucial safeguard—a “hard stop” that prevents the user from accidentally exceeding recommended doses. But the machine must be programmed to do this. Woodington would later testify that none of the Baxa machines in the 22 U.H.S. hospitals she subsequently contacted were programmed with the hard stops for zinc dosage limits. While Woodington and her deputy had entered in some hard stops, such as the acceptable level of viscosity for neonatal drips, they hadn’t programmed limits on trace minerals like zinc.

Typically, the pharmacy will use at most one zinc vial in the Baxa machine to fill all the hospital’s prescriptions for the day. In order to fill Alyssa’s prescription, Cornelius had to refill the machine with zinc 11 times, according to the findings of the pharmacy board. To do this, she used between 45 and 48 vials, depleting the hospital’s entire supply for the month. The resulting amount of fluid was so great, it forced her to use a bag that was twice as big as those reserved for neonates.

Cornelius said nothing of all this when she took the bag to a third pharmacist, Jackson Yu, for approval because, she later testified, she did not know she had done anything wrong. It was 10 p.m., three hours past the deadline for T.P.N. bags to be filled. Yu was the only pharmacist who actually held the bulging bag in his hands, yet he did not notice the error because it was not his job, he would later testify. He was only in charge of verifying that the final supplements Cornelius would add by syringe were correct. By the time the bag reached the NICU, it contained 1,000 times as much zinc as the doctor had prescribed and was larger than Alyssa herself.

The last safety check took place on the nursing floor. One nurse read off Goff’s translation of the prescription, which was on the bag’s label, while another studied the doctor’s original prescription. As the nurse read the number 330 for zinc on the bag, the other saw it on the doctor’s order. They failed to note that the unit measurements, milligrams and micrograms, differed.

At 6 a.m. the next day, Cornelius—who, according to her testimony, had been hesitant to address questions to a pharmacist—sought out a more senior pharmacy technician when she arrived for work. She described the odd T.P.N. order, mentioning that in order to make the bag, she’d had to refill the Baxa compounder with zinc 11 times.

“Are you crazy?” the technician screamed. “What do you mean you refilled it 11 times? For one bag? Where is the order?” As she looked at it, the mistake might as well have been written in neon. Frantic pharmacists called the NICU and told the nurses to stop the drip.

Before long, the interests of the hospital and its pharmacy manager diverged.

U.H.S. wanted Summerlin to be a specialty center that offered more complex care to sicker patients, who needed costlier drugs. Cardinal put its pharmacists under intense pressure to cut costs. “Corporate became very adamant” that its pharmacists use the cheapest drug in cases where more than one drug was an option, says Woodington, who was then working her first stint at Summerlin as Cardinal’s pharmacy manager. “You had two bosses, which was very difficult and not always best for the patient,” she recalls.

As all this played out at Summerlin, the pharmacy became a disengaged temp agency. The staff was poorly supervised, according to Nevada pharmacy board testimony, and its relationship with the hospital staff was tenuous at best. In 2002, U.H.S. replaced Cardinal and brought in McKesson to manage the pharmacies in its 27 hospitals. “I was amazed when I heard McKesson was going in,” Woodington says. “I couldn’t figure out how McKesson was going to undercut Cardinal.”

Under the new contract, McKesson became the pharmacy’s owner, staffed it, bought the drugs, used its own computer systems, and got a daily fee from Summerlin based on the number of patients the hospital treated. Louis Ling, general counsel for the Nevada State Board of Pharmacy, says this kind of total outsourcing arrangement left the hospital blind to what was happening at the pharmacy: “McKesson was insisting on keeping costs down, the hospital was adding new services, and the hospital was hearing from McKesson that everything was great.”

Even before Alyssa’s overdose, the state pharmacy board had become concerned about the safety of McKesson’s practices. In 2006, it began investigating a McKesson-run pharmacy outside Reno—in a hospital also owned by U.H.S.—where two pharmacists were able to repeatedly steal narcotics from a pharmacy safe, despite almost daily computerized discrepancy reports that clearly highlighted the missing vials. As soon as McKesson left the pharmacy, in June 2006, the hospital’s new management team discovered the thefts. In that case, Ling’s pharmacy board accused McKesson of “inadequate” management. McKesson argued in a 19-page response that it had been the victim of “devious” criminal activity by the pharmacists it had hired. In March 2007, Ling’s board dropped its accusations on the condition that McKesson no longer manage a hospital pharmacy in the state without proving to the board that it had improved its operations.

“I don’t know of any board of pharmacy that has set up any regulatory structure to deal with contract pharmacies,” Ling says, adding, “I want very much to prevent the weirdest abuses.”

Responding to questions by email, James Larkin, a McKesson spokesman, contests the notion of any conflict of interest in McKesson’s managing a hospital pharmacy. “We purchase medicines based only on the prescribing practices of physicians,” he says.

Indeed, there are no data detailing how Cardinal’s and McKesson’s dueling roles of pharmaceutical seller and pharmacy manager affect patients. An Institute of Medicine study estimates that 1.5 million Americans are harmed every year by medication errors. These can occur in the best and worst hospitals, with the most and least advanced technology, under any management structure. Last November, at Los Angeles’ Cedars-Sinai Medical Center, a nonprofit teaching hospital regarded as topflight, the twin babies of actor Dennis Quaid were mistakenly given adult doses of the blood thinner heparin after the wrong concentration of the drug was loaded into the dispensing machine.

IV. The Hospital Pharmacy Managers: Cardinal, McKesson

When Summerlin opened in 1997, it was a modest hospital for a sleepy community that had more sagebrush than people. The first company to manage its pharmacy, Owen Healthcare, had been started by a pharmacist with a pilot’s license, who puddle-jumped from hospital to hospital to help out. In March 1997, Cardinal Health, a multibillion-dollar pharmaceutical wholesaler—one of the nation’s three largest companies that buy drugs from manufacturers and sell them to pharmacies—purchased Owen and brought the pressures of a larger company to its pharmacies. In part, meeting shareholders’ expectations meant expanding Cardinal beyond drug distribution, a relatively low-margin business, into pharmacy management, where profits may be fatter but responsibilities are greater.

One thing is clear, however. The Summerlin pharmacy met none of the essential conditions for reducing medication errors as spelled out by Frank Federico, a director of the nonprofit Institute for Healthcare Improvement: a calm pharmacy environment with few distractions, well integrated into hospital operations; stable and consistent staffing; and a culture that encourages the open reporting of errors and concerns. For the staff, Summerlin was a place of chaos and anxiety—conditions that would become painfully clear in the wake of Alyssa’s overdose.

V. Crisis in the NICU

As Kathleen Shinn’s cries filled the intensive-care unit, staffers herded out the other families and steered her and Richard into a nearby conference room. The Shinns recounted that Alyssa’s doctor, Rafael Zenteno, said, “I’ll wait until you’re okay.”

“She’ll never be okay,” Richard said.

When Kathleen demanded to know how this had happened, Zenteno said that he had checked, and his order was written correctly. Kathleen asked for a priest, then insisted on returning to Alyssa’s side. Alyssa’s blood pressure and heart rate were flat. She had effectively died while they were out of the room. “She might not be dead,” a nurse manager said. “Babies are very resilient.”

A cardiovascular surgeon arrived to try to restore her heart rhythm. For the next four and a half hours, the Shinns watched as the hospital tried everything. Alyssa slowly turned purple, and her hands became stiff.

Just after 4 p.m., Zenteno told the Shinns that Alyssa’s prognosis was poor. “If you want to stop, you can withdraw life support,” he offered, as though whether or not she lived would be up to them.

Kathleen was having none of it. “You come back here right now,” she yelled at him. “I want you to tell me my baby is dead.” Muttering in agreement, he finally acknowledged that they should turn off the machines. (Zenteno says he can’t comment on the incident, citing patient confidentiality.) The nurses turned off the ventilator and documented Alyssa’s time of death. For the first time, the Shinns were able to hold her. The tubes tore the fragile skin from her face as they were being removed.

One floor below, Pam Goff’s world as she knew it was also coming to an end. She had returned to the pharmacy that morning, eager to resume her discussion with Woodington, which she’d stewed over the night before. But Woodington was not in her office, and the pharmacy seemed to be under siege. When she asked a fellow pharmacist where Woodington was, a colleague responded that she and another pharmacy supervisor were in the NICU dealing with a bad T.P.N. order.

“Oh my God,” Goff said. “Is the baby okay?”

“No,” said a colleague in the pharmacy. “The baby is crashing, and you typed in the order.”

As the other pharmacist looked her in the face with an expression of pity and horror, Goff began to cry uncontrollably, then to shake and vomit. She was beginning to undergo the nervous breakdown that would bring her to the hospital as a patient. She kept saying over and over, “I would never hurt someone’s child. I have a three-year-old child of my own.” Her husband came to pick her up that morning, but Goff was spiraling downward. She spent the night throwing up.

At 8 a.m. the next day, Goff staggered in for the root-cause-analysis meeting in the administrative boardroom. About a dozen people were there. The purpose of the meeting was to shed light on what had gone wrong, a practice widely regarded as crucial to improving safety in a vulnerable system.

Goff kept leaving to vomit and was finally helped from the meeting by a senior nurse and admitted to the emergency room. She awoke in a haze of Demerol, a painkiller, and Zofran, an antinausea drug, to find Woodington at her bedside. Woodington told Goff that while she didn’t have enough evidence to fire her, she’d work to find it and was now asking for her resignation. Goff refused. Instead, Goff went home and called the state pharmacy board to report herself for making a fatal error.

VI. Epilogue

Alyssa is buried in the Garden of Innocence, a children’s cemetery shaded by pine trees adorned with all kinds of toys. Kathleen hoped that Alyssa would be less lonely there. She tucked a Cat in the Hat book and a Barbie doll into the coffin.

Her nursery is as ready today as it was five months into Kathleen’s pregnancy. The crib is made up with soft pink blankets that match the curtains. Everything a daughter might want is here, even a pair of tiny ballet slippers, size zero to three months. They look huge next to the thimble-size booties Alyssa wore in the hospital. Kathleen has kept those in a plastic bag, hoping to preserve her daughter’s scent.

Three months after Alyssa died, the Shinns separated. They never fought about Alyssa, b

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