According to the report, which is based on a coroner’s report and documents from the Kentucky Board of Nursing, an 81-year-old man with a gastrointestinal bleed was transferred to the hospital last June. A physician had ordered the patient be given colonoscopy prep called GoLytely, but a nurse inadvertently administered a dialysis liquid called Naturalyte.
Kelly Jenkins, executive director of the state’s nursing board, told LEX 18 there were “multiple process failures” that led to the medication mixup and that the nurse involved was not disciplined because of missteps unrelated to her role. The Kentucky Board of Pharmacy is also investigating the incident.
According to a letter the nurse’s attorney wrote to the nursing board, the nurse called the hospital’s pharmacy to let them know that the barcode on the dialysis liquid — which she thought to be colonoscopy prep — would not scan. Instead of sending a new medication, the pharmacy sent a label to the intensive care unit floor via the tube system. According to the attorney’s letter cited by LEX 18, the nurse then administered Naturalyte.
A timeline in the nursing board’s file says the patient was “unable to tolerate” the liquid. The mix-up was caught around midnight and the patient died the following morning, with a coroner’s report stating the patient died from “complications of inadvertent administration (Naturalyte) in the setting of gastrointestinal hemorrhage.”
At the time of the incident, the nurse had been caring for three ICU patients, the attorney’s letter said.
CHI Saint Joseph Health told the news outlet it “honors the privacy of its patients and does not release information regarding their care and treatment. Additionally in agreement with the family of the patient you referenced, CHI Saint Joseph Health will not disclose or otherwise make a comment in response to your request.”
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.
