8-Dec-14 1:00 PM  CST

Oregon Woman dies when Rocuronium instead of Fosphenytoin Administered by Mistake

A Portland, Oregon admitted that patient, Loretta MacPherson, died earlier this week from a medication error initiated during an emergency room visit.  Fosphenytoin, an intravenous drug used to treat seizure disorder, was to be administered to MacPherson, but the paralyzing agent, rocuronium, was administered instead. Rocuronium, which is a neuromuscular blocking agent, is often used during surgical procedures when patients need to be placed on a ventilator. Used under the careful watch of an anesthesiologist, rocuronium is a safe medication, but in this case, because it was administered incorrectly, the drug had fatal results.

            It is unclear how the error occurred, but hospital officials state there will be a full investigation into the error. Questions are being raised about the manufacturer packaging, how the pharmacy compounded the drug, as well as storage and administration of the drug. Officials for the hospital, St. Charles Health Systems, state this is the first incidence of a medical error of this magnitude in the 28-year history of the health system. Officials state there are three individuals involved with the medication error.

            MacPherson, who had recently had brain surgery, stopped breathing and suffered from cardiac arrest shortly after the wrong drug was administered. St Charles Health System reported the incident to the Oregon State Attorney General’s office, but no criminal charges are expected to be charged. Unfortunately, medical errors are responsible for thousands of death each year. This incident comes on the heels of the Health and Human Services department announcing there has been a reduction in the number of deaths related to medical errors from 2010 to 2013. Obviously when an issue such as this arises it serves to remind the medical community that there is still a great deal of work to be done in order to keep patients safe.

 

 

 

 

References:

CBSNEWS (2014) “Hospital medication error kills patient in Oregon”, CBSNEWS,
http://www.cbsnews.com/news/oregon-hospital-medication-error-kills-patient/, retrieved 5. December2014

 

Wozniacka, g., (2014) “Oregon hospital: Medication order killed patient”, YahooNews, http://news.yahoo.com/hospital-says-medication-error-killed-patient-200501465.html, retrieved 5.December 2014


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Source: Sandy Andrews  

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