The deadly medication error that happened at St. Charles Bend (Ore.) hospital originated in the hospital's pharmacy, according to a KTVZ report.
A physician at the hospital ordered an anti-seizure medication for a 65-year-old woman, and that order was correctly placed in the hospital's EMR system and the right order was sent to the pharmacy. Then, however, the IV bag was filled with the wrong medication — a paralyzing agent. But the label on the bag was for the anti-seizure medication, so the clinician administering the drug thought the IV bag contained the correct medication.
A fire alarm went off right after the drug was administered and a staff member closed the door to the patient's room in the emergency department. It took 20 minutes for staff to notice the medication error.
"It is a human error," Robert Gomes, the CEO of St. Charles Bend, said, according to KTVZ.
As a result of its investigation, the hospital has taken immediate steps to make sure another similar error does not occur. Those steps were laid out in a statement and include the following:
- A "safety zone" intended to eliminate distractions in the pharmacy has been enforced where verification of medication will be completed
- A checking process for dispensing drugs has been implemented, and alert stickers for paralytic medications have been added
- Nurses are evaluating the hospital's process of monitoring patients after starting an IV and talking with patient safety experts to make sure best practices are being followed.