By Tara Bannow

The Bulletin

St. Charles Bend’s flat-out admission that a medication error resulted in a 65-year-old woman’s death this week serves as a reminder of hospitals’ efforts to increase transparency and communication when such incidents occur.

Loretta Macpherson, of Sisters, died Wednesday, two days after going to St. Charles Bend’s emergency room. She had been accidentally given a paralyzing agent, which caused her to go into cardiac arrest. St. Charles officials have been forthcoming with Macpherson’s family about the mistake, asserting it’s long been the health system’s policy to do so.

Historically, medical providers have tended to be reluctant to admit fault to patients and their loved ones when serious errors occur out of concern those statements could be used against them in lawsuits. But Oregon and other states have been making a concerted effort to open communication between providers and patients when mistakes happen. An Oregon law that took effect in July encourages providers to tell patients and family when errors occur that result in serious harm or death, although it does not legally obligate them to do so.

Dr. Michel Boileau, St. Charles’ chief clinical officer, said what’s happening currently is not a result of the new law; it has been the health system’s practice for many years.

“The fact that there might be a law or a guideline in place now simply supports the fact that it’s the right thing to do,” he said.

Three St. Charles staff members involved in Macpherson’s care are on administrative leave, Boileau said.

Macpherson went to the emergency room Monday with anxiety and concerns about the medications she was taking after recent brain surgery at Swedish Medical Center in Seattle, Boileau said. St. Charles staff members determined she needed an intravenous anti-seizure medication called fosphenytoin. Instead, she was given the wrong medication, a paralyzing agent called rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage, he said. Macpherson was on life support until Wednesday morning.

Loretta’s son, Mark Macpherson, who said he recently moved from Bend to Sisters to help care for his mother, said the family knew something was wrong when his mother went into cardiac arrest. Before that, she was ready to leave the hospital, he said. Family members asked hospital staff right away what had happened, said Macpherson, 27.

“We didn’t get the answer for a couple of days about what had happened, but when they first told us, it was pure anger,” he said.

St. Charles spokeswoman Lisa Goodman said she can say “with certainty” the family was notified of the mistake before Wednesday.

St. Charles officials are still trying to pinpoint how the error occurred, tracking the drug from when the order was written, when the drug was mixed and labeled and the patient intended to receive it was identified, Boileau said.

“There are a number of steps in there,” he said. “We’ve never had anything like this happen here, so we are in the process of that analysis right now. Before we say exactly what happened, we’re going to make sure that we’re accurate about it. We do know there was a medication error. We acknowledge that. It’s our mistake.”

Macpherson said he’s unsure whether the family will pursue legal action, but St. Charles’ forthcoming approach has been helpful, he said.

“Once it sank in, yeah, it was rather amazing that they came forward and didn’t just sweep this under the rug or try and cover it up, which is what most people would expect,” he said.

Bethany Walmsley, executive director of the Oregon Patient Safety Commission, which collects reports of patient harm resulting from medical errors and helps facilitate mediation under the new law, said St. Charles did the right thing by being open with the family and now trying to get to the root of what happened to make sure it doesn’t happen again.

“The patient’s family has a lot of healing to do, and one of the things that will help a lot with that is as much information as they can get about what they learn through that investigation,” she said.

The public doesn’t learn about most cases of serious harm resulting from medical errors, Walmsley said. So although this case might seem extraordinary, cases of serious injuries or death as a result of medical errors are much more common than people might think, she said.

A groundbreaking 1999 Institute of Medicine report found that as many as 98,000 people die annually as a result of medical errors. A study last year in the Journal of Patient Safety, however, found the numbers to be higher — between 210,000 and 400,000 deaths each year resulting from medical mistakes, making medical errors the third-leading cause of death in the U.S. behind heart disease and cancer.

Nationally, the number of hospital-acquired conditions fell 17 percent between 2010 and 2013, resulting in 50,000 fewer patient deaths, according to a report released this week by the U.S. Department of Health and Human Services.

The St. Charles employees who are on leave are receiving counseling through the hospital’s caregiver assistance program. Boileau declined to say what their jobs are but said they’re “devastated by this.”

“When something like this happens, it’s heartbreaking hard all around,” he said. “It’s heartbreaking for the family, and it’s also heartbreaking and devastating for those who are involved.”

Macpherson said his mother had a benign brain tumor removed in Seattle and had been expected to make a full recovery. Loretta Macpherson worked as an interior designer for 25 years in Newport, he said. Before that, she worked as a clerk in Salem, where her late husband, Gordon Macpherson, had served as a state representative.

“She was a very beautiful person, a very giving person, and she cared about everyone else,” Macpherson said.

Many details from the incident are still unclear. Macpherson said his understanding is that almost immediately after his mother was given the dose of rocuronium, a fire alarm went off that resulted in her being left alone in her room with the door closed.

“It sounds like they gave her the drug and then closed the door on her, so she couldn’t ask for help,” he said. “She couldn’t do anything.”

Macpherson said he doesn’t know how long his mother was in the room before someone checked on her and found her in cardiac arrest. Boileau could not confirm Macpherson was left alone in the room but said there was a “code red” during that time, which means there was concern about a potential fire and doors were closed automatically or manually to prevent the fire from spreading.

Before his mother was taken off life support, Macpherson said, she was unresponsive and experiencing constant convulsions from the brain injury.

Boileau said St. Charles notified the Deschutes County District Attorney’s Office and the Bend Police Department. The District Attorney’s Office did not return a call about whether it is investigating the case.

Macpherson said he went to media outlets with his story because he hopes letting people know about it will prevent it from happening again.

“We want the community to know what happened,” he said. “Precautions need to be taken. The only message we really have is that life is short and you never know when something like this could happen or anything could happen.”

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

8492439