Pharmacy Error Led to Patient Death, Hospital Confirms

A Bend, Oregon hospital is still unsure how a patient received incorrect medication, but does acknowledge a pharmacy worker inadvertently filled an IV bag with a paralyzing agent in place of an anti-seizure medication.

Death Caused by Pharmaceutical Error

Officials have confirmed that 65-year-old Loretta Macpherson died at St. Charles Medical Center, due to a pharmacy worker inadvertently filling an IV bag with the wrong drug.

Fox News reports that Macpherson went to the emergency room at St. Charles and was given a paralyzing agent called rocuronium, which is typically used during surgeries. She was supposed to be given fosphentoin, an anti-seizure medication that she had been prescribed the week before.

She was left alone for 20 minutes after being administered the drug, and suffered cardiac arrest. While the doctors were able to resuscitate Macphearson, she suffered brain damage, and was taken off life support two days later.

According to officials, fosphentoin was correctly entered into the electronic medical records system and the hospital’s pharmacy received the correct medication order. The IV bag was even correctly labeled; however, the investigation revealed that the bag had been filled with rocuronium instead of fosphentoin.

Two hospital workers reviewed the vials of the medication, but failed to catch the error. The health system of St. Charles made a statement and said “While human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients. 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.”

Study Cites Medication Error as Third Leading Cause of Death

• Last year, a study published in the Journal of Patient Safety found that as many as 400,000 people die in the U.S. each year due to medication errors.
• This puts medication errors as the country’s third leading causes of death, behind heart disease and cancer.
• The study was led by John T. James, Ph.D. of the advocacy group Patient Safety America.
• For the study, James and his colleagues analyzed data from four separate studies for instances in which medical error was determined to be the cause of a patient deaths.