Oregon Hospital Apologizes for Fatal Medication Error, Shares Details

An Oregon Hospital recently apologized in person with the family and in writing for a fatal medication error that took the life of 65-year old Loretta Macpherson. The hospital apparently gave the Mrs. Macpherson the wrong drug. Here is text from a letter released by the hospital: "On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient's family along with the caregivers who were directly involved in this case during this incredibly difficult time.

"As soon as the error was recognized, we met with the patient's family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

"The caregivers directly involved in this patient's situation are on paid administrative leave while the investigation continues. They are long-term caregivers who have provided compassionate and skillful care throughout their careers.

"All of us have chosen health care as a career because we have a heart for serving people. When a patient is harmed on our watch it affects us deeply.

"We are committed to handling this tragedy in a transparent and responsible manner that takes into account the needs of the patient's family, our family of caregivers and our community.

Dr. Michel Boileau Chief Clinical Officer St. Charles Health System"

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THEN, this more detailed analysis of the situation, what went wrong, and how errors would be fixed was shared with the public and the media:

Results of Medical Error Investigation

Press Conference Statement - Dec. 8, 2014

As you are well aware, a tragic medication error occurred here last week that resulted in the death of Loretta Macpherson. All of us at St. Charles are devastated by this event. Our thoughts and prayers are with Ms. Macpherson's family and friends during this incredibly difficult time.

After completing our root cause analysis - or internal investigation - we have a more detailed understanding of what led to the medication error.

I would like to first say that while human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients. It is the executive leadership team's responsibility to ensure that processes are in place and those processes are followed. No single caregiver is responsible for Loretta Macpherson's death. All of us in the St. Charles family feel a sense of responsibility and deep remorse.

1. On Monday, Dec. 1, Loretta Macpherson came to the St. Charles Bend Emergency Department for treatment following a brain surgery at Swedish Medical Center in Seattle. The physician who cared for Ms. Macpherson here ordered fosphenytoin, an anti-seizure medication, to be administered intravenously.
2. The drug was correctly entered into the electronic medical records system and the correct order was received by the inpatient pharmacy.
3. The order was read in the inpatient pharmacy, but an IV bag was inadvertently filled with rocuronium - a paralyzing agent often used in the operating room.
4. The label that printed from the electronic medical records system and was placed on the IV bag was for the drug that was ordered - fosphenytoin - although what was actually in the bag was rocuronium.
5. The vials of rocuronium and the IV bag that was labeled "fosphenytoin" were reviewed without the error being noticed.
6. The IV bag was scanned in the Emergency Department, but because the label on the bag was for the drug that had been ordered, the system did not know to sound an alarm.
7. The bedside caregiving staff had no way of knowing the medication within the bag was not what had been ordered.
8. Shortly after the IV was administered to Ms. Macpherson, a fire alarm, known as a "code red," sounded due to an issue in the Heart and Lung Center.
9. A staff member closed the sliding door to Ms. Macpherson's Emergency Department room due to the code red to protect her from potential fire hazards.
10. The paralyzing agent caused Ms. Macpherson to stop breathing and to go into cardiopulmonary arrest. She experienced an anoxic brain injury. She was taken off of life support on Wednesday morning and died shortly thereafter.

Next Steps:

Since Ms. Macpherson's death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.

Issue 1: Incorrect drug chosen and placed into IV

Our Response: We are enforcing a "safety zone" where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.

Issue 2: Verification of drug dispensed

Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.

Issue 3: Monitoring of patient after IV started

Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

Additional steps are forthcoming including bringing in an external pharmacy expert to review our internal processes and provide recommendations for improvement.

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From a disclosure prospective, this looks and feels like the hospital is doing everything right. I'm impressed. There are no weasel words, no hedging in either letter. They appear completely transparent, apologetic, and ready to fix problems -- which what most grieving families want. I hope going forward that the hospital and their attorneys work quickly to address the financial and emotional needs of the family and thus avoid litigation. I also hope they provide adequate support for their staff, including the opportunity for staff directly involved in the mistake to meet with the family and personally apologize. Lastly, I hope when the financial and legal aspects of the case are concluded, that the hospital and family will share their disclosure story with the world.

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