Baby dies as catheter investigation continues at Sunrise Children’s Hospital

An infant has died as a result of disrupted catheter lines at Sunrise Children’s Hospital, according to hospital officials.

Two Sunrise Children’s Hospital nurses — Jessica May Rice and Sharon Ochoa-Reyes — have had their nursing licenses suspended in the wake of a Las Vegas police investigation into 14 incidents of disrupted catheters at the hospital since February.

Rice and Ochoa-Reyes were ordered suspended by the nursing board "in the interest of public health, safety and/or welfare" after the regulatory agency received notice June 10 from law enforcement officials that each nurse was a "person of interest" in an "ongoing criminal investigation."

At the time of the nurses’ suspensions, one newborn was in critical condition and another infant needed an emergency operation.

"The baby who had a disrupted catheter and was in critical condition has passed away," Sunrise spokeswoman Ashlee Seymour confirmed in an e-mail Monday. "One is doing well and has been discharged."

State board of nursing records reveal that police are investigating possible "intentional patient harm" in connection with the injuries suffered by both children.

Seymour would not say Monday when the disrupted catheter incident in the Neonatal Intensive Care Unit occurred.

Though Seymour also would not disclose when the baby died, records at the Clark County Coroner’s office show that a 2-month-old died July 22 in the children’s intensive care unit .

Sunrise officials said they initially thought the problems with catheter tubings — which are used to draw blood and deliver medications and nutrition — were technical in nature. Hospital officials called police in to investigate, they said, when an umbilical catheter, which has a low failure rate, was somehow disrupted.

Las Vegas police spokesman Bill Cassell said Monday that police would not release any details about the child’s death because the case remained under investigation.

Attempts to reach Rice and Ochoa-Reyes were unsuccessful Monday.

Though Seymour refused to answer questions about whether the hospital is now investigating all deaths of newborns at the hospital while Rice and Ochoa-Reyes were on duty, Katherine Ramsland, the nation’s leading criminologist on health care professionals who run afoul of the law, told the Review-Journal in a phone call from her Pennsylvania home that Sunrise will now have to study incidents and deaths in the neo-natal unit "over many months and perhaps years."

Records show Rice received her Nevada nursing license in 2006 while Ochoa-Reyes received hers in 1991.

Luana Ritch, interim chief of the state’s bureau of health care quality and compliance, said Monday that a state investigation won’t be completed until mid-August.

She said little information can be released on the child’s death until the medical examiner rules on a cause of death and a death certificate is issued.

Ritch said she is confident that measures taken by the hospital since the discovery of disrupted catheter lines, including the removal of staff, increased security and the installation of cameras, have made the Sunrise Neonatal Intensive Care Unit safe.

Nurses in Las Vegas and around the state are trying to find out all they can about what happened, according to Susan Adamek, president of the Nevada Organization of Nurse Leaders.

"Any time there are allegations that a nurse has done something that is unprofessional, it doesn’t reflect well on the profession," she said.

A national medical safety expert, who said sometimes fatal mistakes are made in hospitals because catheters are connected to the wrong machine, remained mystified Monday about what happened at Sunrise.

"No one has any idea what ‘catheter disruption’ means," said Mike Cohen, head of the Pennysylvania-based Institute for Safe Medication Practices.

Cohen has long pushed for what he calls "designed incompatibility" to prevent dangerous misconnections of tubes and catheters.

So has Debora Simmons, head of the Houston-based National Center for Cognitive Informatics and Decision Making in Healthcare.

"You can’t put diesel fuel in your gas tank, but you can inadvertently mix medication and nutrition for a baby through a tubing misconnection," Simmons said.

The national Institute of Medicine estimates that as many as 98,000 people die each year in hospitals because of preventable errors.

"I hope we’re talking about accidents at Sunrise," said Cohen recently. "It’s so hard to believe nurses would work together to hurt children."

Contact Paul Harasim at pharasim@reviewjournal.com or 702-387-2908.