Pharmacy Worker's Error Leads to Hospital Patient's Death

DECEMBER 09, 2014
Meghan Ross, Associate Editor
A pharmacy worker at an Oregon hospital mistakenly gave a patient the wrong medication, and the error led to the patient’s death, according to an Associated Press (AP) report.

St. Charles Medical Center officials stated the pharmacy worker filled an IV bag with rocuronium instead of fosphenytoin for a hospital patient named Loretta Macpherson. Rocuronium is a paralyzing agent frequently used during surgeries; fosphenytoin was the antiseizure medication prescribed to the patient.

The prescription was entered correctly into the electronic medical records system, and the pharmacy received the correct medication order, the AP reported. The IV bag was also labeled properly.
After the pharmacy worker mistakenly filled Macpherson’s IV with rocuronium, a second employee did not catch the error while checking the vials of medication and the IV bag for the 65-year-old patient, according to the AP.

The incorrect medication was administered to Macpherson while in the emergency room on December 8, 2014, and shortly after, a fire alarm went off. A staff member locked Macpherson’s door “to protect her from potential fire hazards,” according to the AP.

About 20 minutes later, a nurse went to check on Macpherson, but the patient had experienced cardiac arrest. Doctors resuscitated Macpherson, but she had suffered brain damage, and after 2 days, she was taken off life support, the AP reported.

The AP reported 3 hospital employees have been placed on paid administrative leave, and the health system stated it would be making several changes to prevent mistakes such as this from happening again. For example, the hospital will enforce a “safety zone” in its pharmacies so that staff members have fewer distractions, and an external pharmacy expert will be brought in to provide recommendations, according to the AP. The hospital will also consider how its patients are monitored after they are given medication.

“While human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients,” the health system said in a statement. “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.”



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