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SUPPLEMENT/CONTINUATION
On November 30, 1992, two R.N.’s from the Post-Anesthesia Care Unit wrote a letter indicating that, over the past few months, Dr. Fitzgerald started injecting Fentanyl (Sublimaze) in many of her epidural pain block patients. The letter stated the following:
“On Friday, November 27, 1992,1 was assisting Dr.
Fitzgerald
with an epidural injection. For these injections, Dr. Fitzgerald opens the epidural tray. She then draws up
two
CC’s of Fentanyl In a 3 CC syringe and squirts a
half
to 2 CC’s of the medication Into a small cup on the epidural
tray
prior to putting on sterile gloves and doing the procedure. On
this
date, It appeared to me that, after drawing up the Fentanyl, she placed the syringe In her jacket pocket and took out another filled 3 CC syringe from the opposite pocket and used It when
she instilled the medication on the tray. I
did
not question her at this time. However, she made the comment to me “Oh, I put that syringe in my pocket and I shouldn’t do that...It’s a bad habit.” She used 1
1/2
CC’s of the solution and gave me back the syringe with the remainder for disposal. However, I saved the syringe. I was concerned about what I thought had occurred, so I asked my charge nurse, Sylvia
N., to watch Dr. Fitzgerald closely while she was assisting her with the next blocks. Sylvia Informed me that It also appeared to her that, with one of the blocks, Dr. Fitzgerald placed the syringe of Fentanyl In one pocket and used a different syringe from another pocket. Sylvia also saved the unused solution and syringe. I expressed my concerns to
until Monday. I locked up the syringes from the blocks, as well as filled
“On Monday, November 30, 1992, there were
six
blocks for Dr. Fitzgerald on this date.
During two
of these blocks, Sylvia
saw
Dr. Fitzgerald place the
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