‘Tragic error’: St. Charles probing wrong-drug death

A Sisters woman admitted to St. Charles Bend for treatment of anxiety was given the wrong medication and died two days later as a result, a family member said and hospital officials confirmed Wednesday.

The hospital said all employees involved in the tragic sequence of events have been placed on paid leave amid an ongoing investigation. The Deschutes County District Attorney’s Office is conducting a death investigation, but DA Patrick Flaherty said that is the process for all deaths, including accidental ones.

Loretta Macpherson, 65, was taken off life support and passed away Wednesday, less than two days after arriving at the Bend hospital, her son, Mark Macpherson of Bend told NewsChannel 21.

“She was the most amazing person on the planet,” Mark McPherson said. “There wasn’t a person that she didn’t get along with. Everyone loved her.”

Macpherson said several hospital staff members confirmed she was given the wrong medication, before going into cardiac arrest.

“They administered a paralyzing agent to my mom, instead of an anti-seizure medication, and stopped her from breathing and stopped her heart,” he said.

Loretta Macpherson died Wednesday morning, just two days after arriving at the St. Charles ER to be treated to St. Charles for anxiety — and only a month of recovery after having a brain tumor removed at Swedish Medical Center in Seattle.

“Very speedy recovery, she was expected to make a full recovery,” her son said. “She was doing very well.”

St. Charles Bend officials confirmed that Loretta Macpherson was given the wrong medicine.

“We believe that a tragic medication error occurred,” said Dr. Michael Boileau, clinical chief officer for St. Charles Health System. “And that mistake, that error, has caused her death. This appears to be a misidentified medicine. We thought we are going to give one medicine,and we gave another medicine.”

The hospital issued the following statement Thursday:

“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”

It’s a mistake that took Mark Macpherson’s mother, too soon.

“I don’t — I can’t begin to explain the emotions and the feelings that are going through me,” Mark Macpherson said, “because I’ve never felt them before.”

The St. Charles official called it a tragic first – one the hospital will work hard to never repeat.

“We mix and dispense thousands of very dangerous drugs every year,” Boileau said. “And I’ve been here almost 30 years. We’ve never had something like this happen before.”

Boileau told The Associated Press Thursday that Macpherson came into the ER Monday with medication dosage questions after her recent brain surgery.

Boileau said she was given a paralyzing agent typically used during surgeries, instead of an anti-seizure medication. He said Macpherson stopped breathing and suffered cardiac arrest and brain damage as a result.

The organization doesn’t yet know how the error occurred, Boileau added.

Mark Macpherson would not confirm whether he’s planning legal action against the hospital. But he said he does not want anyone else to have to experience what he has.

St. Charles officials said three employees involved in Loretta Macpherson’s care have been placed on administrative leave, and the hospital contacted the district attorney’s office. They said they do not yet know when the investigation will be completed.

Deschutes County District Attorney Patrick Flaherty told NewsChannel 21 in an e-mail Thursday that, as in all accidental deaths, “the law required a death investigation. However, I did not and am not requesting an autopsy, because there is no question about the cause of death.”