Inspection report faults Boston Children's for medication errors linked to patient death

In 2017, three patients suffered from medication errors at Boston Children's Hospital, including one patient who waited 14 hours for an antibiotic and later died, according to a state and federal inspection report cited by The Boston Globe.

Here are eight things to know.

1. The errors took place between January and November 2017 and involved two drugs. The mistakes prompted federal regulators to threaten Boston Children's with termination from the Medicare program.

2. For the patient who died, caregivers ordered an antibiotic, Zosyn, at noon on a day the patient was receiving treatment in the hospital's intensive care unit. However, the inspection report revealed a nurse did not give the patient the antibiotic until about 2 a.m. the next morning. The patient developed sepsis and died two days later. After the antibiotic was prescribed, the patient's nurse mistakenly thought someone had given a verbal order to hold the medicine for further test results.

After the patient's death, hospital leaders sent an alert to physicians and nurses in the intensive care unit to remind them all medication orders should be in writing to avoid confusion — except in an emergency. Inspectors said the hospital failed to alert caregivers across the hospital about the rule.

3. Two other Boston Children's patients received overdoses of the anesthetic Propofol. After the first overdose in January 2017, hospital leaders suggested implementing a clearer procedure for measuring doses.

Inspectors interviewed one of the hospital's pharmacists, who claimed those recommendations "never materialized," according the report. Ten months later, a physician administered an overdose to a different patient using the same potentially confusing procedure. That second patient stopped breathing and was resuscitated, but hospital executives said both overdose patients recovered. 

4. After these incidents, this spring, the hospital implemented improvements for treating sepsis patients quickly and for administering Propofol accurately, avoiding CMS discipline.

5. Jonathan Finkelstein, MD, chief patient safety and quality officer for Boston Children's, did not discuss specific cases, but told The Boston Globe when there is a misstep "we set out the very next day to improve care."

6. In the 46-page report, inspectors said the hospital did not completely analyze the errors and thoroughly correct the conditions that led to the errors. Inspectors based report findings on visits to the hospital over five days in November and December 2017.

7. Dr. Finkelstein said the hospital put a new protocol in place that triggers a sepsis evaluation for any patient with a deteriorating condition. Additionally, Boston Children's sent out a hospitalwide alert that states when medications are handed off to another clinician, only a single, labeled, weight-based dose can be prepared in a single syringe.

8. In a 63-page improvement plan, Boston Children's recognized "the need to focus additional attention in our responses to specific events," including "the potential of a similar event occurring in another area."

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