ABSTRACT

The Mary McClinton Story „e case of Mary McClinton’s death at Virginia Mason Medical Center (VMMC) (Seattle, WA) is well known in patient safety circles. McClinton died in 2004 after being injected with chlorhexidine, an antiseptic solution, instead of a contrast dye. During her procedure, there were three clear liquids that were kept in stainless steels bowls on a tray: the antiseptic, the dye, and a saline solution. Anticipating the interventional radiologist’s need, an experienced technician prelabeled an empty syringe as “contrast dye.” However, he later allegedly filled the syringe with the antiseptic, not the dye.1 A Lean thinker would recognize the potential for systemic error in a situation like this and would not be satisfied with well-trained people being careful. „e error that caused McClinton’s death was an accident waiting to happen.