Tag Archives: execution

Root Cause Analysis

Lethal-Injection Drug Mix-up

By ThinkReliability Staff

On January 15, 2015, a prisoner was executed by lethal injection in Oklahoma. On October 8, the autopsy report, showed that prisoner had been injected with potassium acetate instead of potassium chloride as intended.

This was the first injection to take place in the state since a prisoner took 43 minutes to die after the drugs were administered in April 2014 (see our previous blog about this execution).  After that, further executions were stayed.

Just hours prior to the first execution scheduled since January, Department of Corrections personnel realized they were sent potassium acetate instead of potassium chloride and that execution was called off.  Shortly afterwards, an Oklahoma court granted an indefinite stay for the prisoners who were scheduled for execution.

While there is ongoing debate about whether the change adversely impacted the speed or humaneness of the execution, it certainly caused great concern about the ability of the state of Oklahoma to correctly perform an execution.  Says an attorney, “The state’s disclosure that it used potassium acetate instead of potassium chloride during the execution of Charles Warner yet again raises serious questions about the ability of the Oklahoma Department of Corrections to carry out executions.”

Along with the concern for ability to perform future executions, there is potential safety impact regarding the prisoner’s suffering, as well as the production impact resulting from the delay in future executions.  The ongoing investigation will also impact goals because of the resources required.  This investigation will attempt to determine how the wrong drugs were used in the execution.

In case of the execution scheduled for September, the wrong drug was placed in the syringe used to inject the prisoner, and there was an ineffective verification of the drugs.  It’s unclear whether there was an attempt at verification that the drugs being used were correct.  If there was such a check, verification may have been difficult because records show that the syringe was labeled potassium chloride (the desired drug).

Department of Corrections records also show that the state received potassium acetate instead of the desired potassium chloride.  It seems that the potassium acetate was accidentally delivered from the supplier (there doesn’t appear to be a need for potassium acetate).  According to the prisons director, the supplier believed that the drugs were interchangeable.  In general, the oversight of suppliers who provide lethal injection drugs is limited – many states refuse to disclose their suppliers and many suppliers are compounding pharmacies, which are subject to less regulation.

Oklahoma does have several different combinations and substitutions of drugs allowable for executions, but there is no approved substitute for potassium chloride.  This, and recent changes to suppliers because so many refuse to supply drugs for lethal injection, may have led to some confusion.

It’s likely that solutions, or changes to the execution protocol may not be discussed until after the investigation is complete.  A completely different type of execution may be considered: in April 2014 Oklahoma approved nitrogen gas the backup method for executions if lethal injection could not be used.  Based on all the recent issues and concerns, that new method may be under consideration.

Root Cause

Lethal injection fails to quickly kill prisoner

By ThinkReliability Staff

While the use of the death penalty remains highly controversial, there is general agreement that if it is used, it should be humane.  The execution of a prisoner in Oklahoma on April 29, 2014 did not meet those standards.  The inmate died 43 minutes after the drugs were injected.  (Typically death takes 5-6 minutes after injection.)  According to Jay Carney, the White House Spokesperson, “We have a fundamental standard in this country that even when the death penalty is justified, it must be carried out humanely – and I think everyone would recognize that this case fell short of that standard.”

The details surrounding this case can be captured in a Cause Map, or visual root cause analysis, to examine the causes and effects of the issue.

The problem being evaluated is the botched execution of an inmate in the Oklahoma State Penitentiary. The execution began at 6:23 pm on April 29, 2014.  An important difference in this execution, compared to other executions, is that it was the first time the state had used the drug midazolam as part of the three-drug injection protocol.  The protocol, when originally developed in 1977, called for sodium thiopental, followed by pancuronium bromide and potassium chloride.

The safety goal was impacted in this case because of the failed execution.  The public service goal can be considered to be impacted as the execution was called off (after all three drugs were administered; the prisoner later died of a heart attack.)  The schedule goal is impacted because all future executions have been called off.  The state planned a two-week postponement of the next execution (scheduled for later the same day) in order for a review of this investigation to be completed, but at the time of this writing, that execution has not yet been scheduled.  Executions across the country have been appealed or stayed and none have taken place since April 29th.  The labor/ time goal is also impacted due to the investigation into the execution, which has not yet been published.

These goals were impacted due to the failure of the lethal injection.  The process intended to be used for this lethal injection is detailed on the downloadable PDF.  However, from the start things didn’t go smoothly.  Instead of using two IVs, one in each arm, only one IV was able to be connected, in the patient’s groin.  Because sodium thiopental is no longer available (drug companies will no longer provide it for use in lethal injections), the drug midazolam was used instead.  However, the protocol for using that drug is disputed.  In Florida, five times the amount of midazolam is used.  In Oklahoma, midazolam is used along with hydromorphone.  Because of the debate about lethal injection, most states don’t divulge their suppliers, so the efficacy of the drugs used cannot be verified.  In addition, there is generally at least one doctor present to oversee the executions, but these doctors are not usually identified and may not participate in the actual administration of the drugs because many medical organizations ban doctors from participating on ethical grounds.

At this point, it’s unclear what will happen at future executions.  The investigative report being prepared by the state of Oklahoma may give some suggestions as to how to make lethal injections more humane in the future, or this may tilt the scales towards ending lethal injection, or executions altogether.

To view the Outline, Cause Map, and Process Map, please click “Download PDF” above.