Click here to see the investigation reports.
Four months before a 65-year-old Sisters woman died after being given the wrong medication at St. Charles Bend, the hospital had stopped using an electronic medication check system that Deschutes County District Attorney John Hummel says would have prevented the death.
“There is no question that a digital medication check program would have caught the medication error that lead to MacPherson’s death,” Hummel wrote in his investigation released this week, two years after the December 2014 error that resulted in Loretta Macpherson’s death. “Indeed, representatives for St. Charles concede, ‘if DoseEdge would have been in place and the process followed then the error would not have occurred,’” the DA said in his investigation report.
Click here to see the investigation reports.
St. Charles Health System’s pharmacy director, however, disagreed with that assessment, arguing that even if such a system had been in place, there is no guarantee the employee involved would have used it.
Hummel declined to file criminal charges against St. Charles or its employees related to the death — which occurred after Macpherson was given the paralyzing agent rocuronium instead of the anti-seizure medication, fosphenytoin, her doctor had ordered — although his report acknowledged a series of mistakes made by the health system and its employees.
Hummel concluded nothing would be gained from a criminal conviction. The fine associated is relatively small and, more importantly, St. Charles had already agreed to make the changes he deemed necessary to prevent similar mistakes.
“I dug into this case, went after St. Charles hard,” Hummel said, “and I was on the verge of filing criminal charges, but we got to the point where St. Charles made every change I asked them to make, every improvement in their system I asked them to make.”
One important change that hasn’t yet been made: St. Charles still doesn’t have an electronic medication check system. It won’t get one until April 2018, when it goes live with its new electronic health records system, Epic.
Concern about mistakes
St. Charles officials did not mention in previous interviews about the incident that the lack of an electronic check system may have contributed to the patient’s death. They lost access to the system, called DoseEdge, in August 2014 when they switched to a new electronic health records platform called Paragon.
Michael Powell, St. Charles’ pharmacy director, said before the health system implemented Paragon, representatives from both Paragon and DoseEdge assured them the systems would be compatible.
“We later learned they were not,” he said.
At the time of Macpherson’s death, pharmacy employees performed manual medication checks, which they still do. Before the incident occurred, employees had warned administrators about the risk of an error happening under such a model. In fact, the DA’s investigation referenced a number of near misses “where patients almost received or actually received improper medication.”
Joanne Kennedy, the pharmacy technician who accidentally retrieved the wrong medication for Macpherson, told a police detective in an interview that everyone was concerned about accuracy and safety after St. Charles stopped using DoseEdge.
“The pharmacists were concerned that a big mistake would be made on their watch,” Detective Robert Jones of the Bend Police Department relayed from his interview with Kennedy. “Kennedy explained they were getting busier and busier and staff was working faster and the chance of an error was on everyone’s mind and DoseEdge made it quite a bit safer. Kennedy stated the technicians complained to the pharmacists, the pharmacists complained to the pharmacy management, and the management complained to the administration.”
At the time she retrieved the wrong medication, Kennedy, who could not be reached for comment, had been on her eighth straight day of work. A 37-year veteran of the hospital, staff often referred to her as an “expert” in the pharmacy department, according to a Bend Police Department report. In her police interview, she said she does not know why she took the wrong medication. She surrendered her license with the Board of Pharmacy following the incident.
Rebecca Berry, St. Charles’ vice president of human resources, said it’s not the health system’s normal practice to have employees working eight days in a row. In Kennedy’s case, she had voluntarily picked up a shift.
DoseEdge use still rare
In hospitals that use DoseEdge, pharmacy employees scan individual medication ingredients through the system before mixing them for patients. The system verifies ingredients against the doctor’s order. In this case, such a scan would have alerted the employee to the ingredient that should not have been used.
Ray Vrabel, a pharmacist and medication systems strategy consultant in San Diego who has spoken with people at St. Charles about the Macpherson case, said he agrees with Hummel’s assessment that DoseEdge would have prevented the patient’s death — that is, unless the employee had deliberately chosen to ignore the software.
“Had DoseEdge been in place, it would have warned the technician that, ‘Hey, you’ve got the wrong vials,’” he said, “and they’d go, ‘Oh my god. I do have the wrong vials! Look what I did!’ And they would put them back and get the right vials and nobody would have known the difference.”
Given that the emergency department had been urging the pharmacy technician to get the medication ready quickly, Powell said there is no guarantee she would have scanned the ingredients through DoseEdge if it had been available.
“I’d be speculating to say whether that product would have in fact prevented the tragic error from occurring,” he said.
When the incident occurred in December 2014, only about 5 percent of hospitals had systems like DoseEdge in place, said Allen Vaida, executive vice president with the Institute for Safe Medication Practices. Today, he thinks it’s likely around 15 percent of hospitals.
Even so, Vaida, a pharmacist, said his organization, which inspected St. Charles after Macpherson’s death, strongly recommends such systems for hospitals in order to prevent such mistakes.
“Now, two years later, we’re actually really pushing hospitals to put this at the top of their agendas,” he said.
St. Charles implemented a series of recommendations from the Institute for Safe Medication Practices following Macpherson’s death, Powell said, including a checklist pharmacists must go through before a medication is dispensed.
St. Charles CEO Joe Sluka said the health system is dedicated to improving its processes to make it as safe as possible.
“This is a terrible tragedy that happened through a tragic mistake,” he said. “From the organizational standpoint, there is not a day that goes by that we don’t think of Mrs. Macpherson and her family.”
St. Charles paid an undisclosed amount of money to Macpherson’s family under an out-of-court settlement earlier this year.
Missed red flag
St. Charles’ manual medication check system requires that pharmacists approve medications from technicians before they go to patients.
In this case, before the IV bag went to Macpherson, the pharmacy technician presented the pharmacist, Sheena Fischer, with the rocuronium-filled IV bag labeled as fosphenytoin, the drug the patient was supposed to receive, as well as the empty vials of rocuronium and a syringe, according to the DA’s report.
Without completely checking the medication, the report said, Fischer confirmed it was the medication Macpherson’s physician had ordered.
Vrabel said he doesn’t fault Kennedy, the pharmacy technician, for making a human error. She even placed the rocuronium warning label that says “neuromuscular blocker” on the IV bag, he said. He does, however, fault the pharmacist for not picking up on obvious clues when she checked the pharmacy technician’s work, including the sticker on the IV bag.
“That should have been like, again, another charge going through their body or red flag, ‘Why is this sticker on fosphenytoin? That’s not right.’”
Before Macpherson received the fatal medication, her physician had ordered continuous cardiac and pulse oximetry monitoring, which would have sounded an alarm when her condition deteriorated.
According to Hummel’s report, nurse Susan Taylor acknowledged that order but did not follow it. In an interview with The Bulletin, Taylor said she did not recall whether she placed Macpherson on the monitoring. Before Taylor left the room, Macpherson was up, alert and walking to the bathroom unassisted. In fact, Macpherson — who had gone to the ER for anxiety related to a recent brain surgery — was set to leave the hospital after receiving the anti-seizure medication, Taylor said.
“It is not uncommon, when the patient has exhibited stability throughout that visit, that the patient is taken off the monitoring system,” she said. “That’s not at all uncommon. And again, with that medication that was supposed to have been in the bag, it would not at all have been out of line to not be monitoring the patient.”
Jane Cleavenger, the nurse who administered Macpherson’s IV, also said she likely saw the sticker, but she said she didn’t know what it meant, and administered the drug anyway, according to the DA’s report.
The DA’s investigation said proper administration of fosphenytoin — the drug Macpherson was supposed to receive — requires monitoring for 10 to 20 minutes afterward. Had Cleavenger stayed with Macpherson, the report said she would have noticed something was wrong within one to six minutes and would have been able to put in a breathing tube, saving her life.
Cleavenger, however, left the room after starting Macpherson’s IV because of a fire drill. When she returned 42 minutes later, Macpherson was unresponsive. She was taken off life support two days later on Dec. 3, 2014.
Fischer declined to comment. Her Oregon pharmacy license is still active. Cleavenger did not return a call seeking comment. Her Oregon nursing license is still active.
‘It was not safe’
Hummel’s investigation also included interviews with St. Charles employees who weren’t involved in Macpherson’s care, including John Nangle, a nurse who works in St. Charles Bend’s emergency department and serves as a member of the hospital’s staffing committee. Nangle said the ER was “grossly understaffed” the day Macpherson died, and believed it still was at the time of his interview in October 2015.
Hummel’s office also interviewed Vikki Hickmann, another emergency room nurse at St. Charles, in September 2015. She told an investigator St. Charles was going through a “staffing crisis” and needed to evaluate its staffing levels.
“The community has grown a lot, people are sicker, people are a lot more complex to take care of, and they require more hours,” according to the DA’s report. “Hickmann stated her department had been talking to them (management) about staffing levels for a long time and they didn’t think they (management) were staffing properly.”
After those interviews, Hummel said he talked to St. Charles about staffing issues and felt reassured.
“St. Charles is staffed more appropriately now than they were then, and I took that into consideration,” he said.
St. Charles has hired 10 new pharmacy technicians this year, Powell said. The department has also eliminated the need for pharmacy technicians to serve in stand-by or on-call capacities, he said.
Macpherson’s death contributed to Taylor’s decision to quit St. Charles in early 2015. Staffing was a major issue for nurses in the emergency room, she said, and she ultimately felt she didn’t have the resources to be the nurse she wanted to be.
“It was just total chaos,” Taylor said. “All of our staffing pattern in the ER was to the point that it was not safe.”
— Reporter: 541-383-0304,