Home >  News >  December, 2014

Fatal Medication Error Has Hospital Reeling

Patient was given a paralyzing muscle relaxant instead of an anti-convulsant.

Published: December 5, 2014

A head-scratching and tragic medication error has a devastated Oregon hospital scrutinizing every aspect of its medication process to try to understand how a 65-year-old patient was given rocuronium, a paralyzing muscle relaxant used during intubation, when she should have been given the anti-convulsant, fosphenytoin.

Loretta Macpherson, who'd recently had brain surgery, had come to the Emergency Room at St. Charles Medical Center in Bend, Ore., on Monday, with medication questions, says Michel Boileau, MD, chief clinical officer of the St. Charles Health System. She went into respiratory and cardiac arrest after being given the wrong drug in the ER, and died 2 days later.

St. Charles, says Dr. Boileau, is now examining how it orders drugs, how the hospital pharmacy mixes, packages and labels them, how they're brought to nurses, and how drugs are administered. Three St. Charles employees have been placed on paid administrative leave while the investigation proceeds. "We're looking for any gaps or weaknesses in the process," says Dr. Boileau. "For something like this to happen, it's devastating for her family, but it's also devastating for the hospital staff who are involved in this."

"Without knowing what happened, it sounds as if there was a failure to read the label at least 2 times," says Sheldon Sones, RPh, FASCP, president of pharmacy-consulting firm Sheldon Sones and Associates. Mr. Sones also points out that even when generic names of drugs don't sound alike, trade names and shortened names can be confused. For example, Zemuron (rocuronium) sounds similar to Zarontin (a trade name for ethosuximide, a sister drug to fosphenytoin). Likewise, if someone simply asks for "sux," meaning ethosuximide, it can be confused with succinylcholine (suxamethonium chloride), a sister to rocuronium.

The Institute for Safe Medication Practices provides a frequently updated list of confused drug names.

Jim Burger

Also in the News...

Novel Stress Test Determines When Surgeons Are Ready to Cut Loose
Orthopod Accused of Supplying Painkillers to His Mistress
Ophthalmologist Sues Over "Unconstitutional" Certificate-of-Need Process
Jury Awards $870K to Man After Surgeon Amputates Wrong Testicle
All 16 Reprocessed Ureteroscopes Tested in Study Were Still Contaminated
For Surgical Sales Reps, It's All About Bonuses and Commissions
What Caused Mold to Grow in Sterilization Sink?

New to Outpatient Surgery Magazine?
Sign-up to continue reading this article.
Register Now
Have an account? Please log in:
Email Address:
  Remember my login on this computer

advertiser banner

Other Articles That May Interest You

Is Double-Booking ORs All Bad?

In Case You Missed It...

Top 10 viewed features on outpatientsurgery.net

What We Can Learn From 5 Years of Malpractice Claims Data