Oregon Woman Dies From Hospital Medication Error

Published on December 10, 2014

A hospital in Bend, Oregon is investigating how a patient was administered the wrong medication, leading to her death.

Loretta Macpherson, 65, came to the ER earlier this month with medication questions after a recent brain surgery. Upon arrival, doctors determined Loretta needed an intravenous anti-seizure medication called fosphenytoin. Instead, she was accidentally given rocuronium, a medication often administered to patients in the operating room when attached to a ventilator. The mistake was deadly.

Loretta stopped breathing and suffered cardiac arrest, leading to irreversible brain damage. Loretta was taken off life support two days later.

Three employees involved in the error have been placed on paid administrative leave as St. Charles Health Systems investigates what happened. The investigation includes looking into how the medication was ordered from the manufacturer, how the pharmacy mixed, packaged and labeled the drug, how it was brought to the nurses and how it was administered to Loretta.

Loretta is survived by her two sons, Mark and Pete, who describe their mom as a beautiful soul and a people person.

Sadly, thousands of families lose a loved one from a preventable hospital error every year. A study published in the Journal of Patient Safety last year estimates that 210,000 to 440,000 patients die each year from a preventable hospital error. This is a huge increase from a 1999 study from the Institute of Medicine that estimated 98,000 deaths every year from preventable hospital errors.

Loretta’s story and the hundreds and thousands of others that die each year from preventable hospital errors serve as proof that hospitals need to reevaluate every policy, technology, and practice in place. In doing so, hospitals can work to reduce the amount of errors annually, potentially saving hundreds of thousands of lives.

In order to help protect yourself from medication errors, the National Institutes of Health recommends that you do the following:
-Tell your nurse and doctor about any allergies or side affects you have to any medications.
-Keep a list of every medicine, vitamin, supplement, and herbs you take in your wallet.
-Do not take any medication of your own unless your doctor tells you it’s okay. Be sure to tell your nurse if you take your own medication.
-Ask what medication you’re being given in the hospital include the name, what it does and its side effects, and what time and how often you’ll be getting them.
-All syringes, tubes, bags and pill bottles should have a label on them. If they don’t, ask your nurse what it is.
-Ask your nurse if you’re taking any “high alert” medicine. These can cause harm is not given the correct way. High alert medications include blood thinners, insulin, and narcotic pain medicines. Also ask what extra safety steps are being taken.

Far too often, patients and their families are afraid to question their doctor or nurse. If you feel uncomfortable, let them know that you’re taking an active role in your healthcare. They’ll understand and they might even thank you for it.