St. Charles Medical Center staff told a packed news conference that they believe they know how the wrong drug was given to former Newport resident Loretta Macpherson, which caused her death last week. Somebody in the hospital pharmacy put the right label on the wrong drug.
Macpherson entered the Bend hospital December 2nd suffering discomfort after undergoing brain surgery. But instead of being injected with an anti-seizure medicine, she was given a paralyzing drug used during major surgeries.
How could such different drugs have been so completely confused?
Hospital officials said that once a drug is placed in an I-V bag at the hospital pharmacy and then labeled, no one knows if it’s not the drug that the label says it is. And that, according to hospital officials, is what killed Macpherson.
It was in the pharmacy, they say, that a paralyzing drug was misassigned to an I-V bag that was destined for Macpherson’s room.
At Macpherson’s bedside the I-V bag was lifted onto the support rack. The nurse read the label clearly indicating that it was an anti-seizure drug. She started the I-V. Suddenly the hospital fire alarm went off – the nurse closed the doors to Macpherson’s room as a precautionary move and then left to tend to matters related to the alarm.
She was gone for 20 minutes.
She returned to Macpherson’s room and immediately knew something had gone terribly wrong. Macpherson was not breathing. The nurse immediately started CPR and called for help. But it was too late.
Hospital staff said they are taking every step to ensure something like this never happens again. Three hospital staff working in the pharmacy December 2nd have been placed on paid administrative leave. Hospital officials say the mistake was likely made by a single worker.
St. Charles has hired pharmacy safety experts who will analyze every time-motion element in the selection, checking, verifying and delivery of all drugs to every department in the hospital. They’ll check handling and labeling protocols and will closely monitor pharmacy drug prep-room behavior to eliminate distractions that can interrupt a technician’s concentration when handling highly dangerous drugs.
In the meantime, Macpherson’s son who lives in Sisters, OR, just up the road from Bend, says the family has hired an attorney aimed at mounting a lawsuit against the hospital.