According to the report, hospital nurses inappropriately programmed patient-controlled pumps, causing the three patients to overdose. In one of those cases, a patient who was supposed to receive 6 milligrams of morphine through the pump was instead administered 30 milligrams.
In addition to the three fatalities, state investigators found one patient required treatment after receiving an improper dose of medication through a pump. In the previous four cases and three others, investigators also found hospital staff failed to document the errors properly, according to the report. Other deficiencies include failure to get a physician’s authorization to use restraints on patients and failure to report patients with infectious disease to state officials.
The state investigation led regulators to declare St. Luke’s as an “immediate jeopardy” on Nov. 17, though that status was removed a day later when hospital officials established a corrective action plan. That plan includes enhanced employee training, new pumps, increased monitoring of patients and more.
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