Safety crusade: The legacy of Mary McClinton’s tragic, preventable, death (12 June 2026)

Summary

Mary McClinton, 69, arrived at Virginia Mason Medical Center one day in November 2004 for a complex but routine procedure. She had been diagnosed with a brain aneurysm, and doctors planned to place a stent in an artery and then inject dye into her bloodstream for an imaging test. The procedure appeared to go according to plan, but she awoke in terrible pain. The team worked feverishly to determine what had happened and how they could help her, but she never recovered. Mrs. McClinton never left the hospital. Nineteen days after the procedure, she died.

At first, the team was mystified as to what had happened to cause her death. After carefully reviewing every step along the way they finally found the culprit. A topical disinfectant solution, chlorhexedine, had been mistaken for the injectable dye. In fact, the disinfectant, injectable dye, and a saline solution - three visually identical clear liquids - were all placed in unlabeled stainless steel bowls in the procedure room. At some point, the disinfectant - highly toxic if used internally - was drawn up into the syringe meant for the dye. A tragic, fatal, and wholly preventable mistake.

At that moment in time, late 2004, Virginia Mason was a couple of years into its journey to apply the Toyota Production System to its own work through the Virginia Mason Production System. This approach is all about constantly examining and improving processes - and the system is intended to prevent dangerous errors completely.

In the months after Mary McClinton’s death, Virginia Mason decided to make patient safety the organisation’s singular goal.