Wrong drug put in IV bag led to fatal Bend hospital error

A St. Charles Bend pharmacy worker put the wrong medication in an IV bag, leading to the fatal error that killed a Sisters woman last week, hospital officials said Monday in an update on the ongoing investigation.

“It is a human error,” Robert Gomes, CEO at St. Charles Bend and Redmond, told reporters at a news conference.

Macpherson’s physician ordered an anti-seizure medicine, officials said, and the order was received correctly at the pharmacy.

But for as-yet unknown reasons, a worker at the pharmacy then put a paralyzing agent in the IV bag, instead of the prescribed anti-anxiety medicine. Yet the label on the bag indicated it contained the anti-anxiety medication.

“Because the label on the bag was that for the drug that had been ordered, the staff (at the ER) had no way of knowing the drug that was actually in the bag was not the one that was ordered,” said Dr. Michel Boileau, chief clinical officer at St. Charles Bend.

After Loretta Macpherson, 65, of Sisters received the medication, a fire alarm went off. A staff member closed the sliding doors of Macpherson’s room to protect her from fire hazards.

St. Charles Bend and Redmond Chief Nursing Officer Karen Reed said it took officials 20 minutes to notice the medication error.

A week ago, Macpherson of Sisters went to the St. Charles Bend Emergency Department for treatment following a recent brain surgery.

While in the ED, Macpherson was intravenously administered a medication other than the one her attending physician prescribed. The error caused Macpherson to go into cardiopulmonary arrest. She was taken off of life support two days later.

Here’s the full statement read at the news conference:

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.

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.
The drug was correctly entered into the electronic medical records system and the correct order was received by the inpatient pharmacy.
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.
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.
The vials of rocuronium and the IV bag that was labeled “fosphenytoin” were reviewed without the error being noticed.
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.
The bedside caregiving staff had no way of knowing the medication within the bag was not what had been ordered.
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.
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.
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.

In regard to the caregivers most directly involved in Ms. Macpherson’s care, we are following our standard Human Resources protocols. No personnel decisions have been made at this time.

We have voluntarily reported the error to licensing and reporting agencies.

Once again, we are devastated by the loss of Ms. Macpherson’s life. We hope that by openly sharing the details of what led to her death we will not only help bring peace and understanding to her family, but will help other health care institutions avoid making a similar series of mistakes.

All of us at St. Charles 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 apologize sincerely for this tragic error, and are committed to doing all we can to provide safe and compassionate care to our current and future patients.

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Three employees have been placed on paid administration leave, pending the results of the investigation, which has not yet concluded, officials said. They said they don’t have a timeline for when the investigation will be finished.