CSP error results in death of a patient

A 65-year-old woman died at St. Charles Medical Center in Oregon after being given an infusion of rocuronium instead of fosphenytoin.

“The prescription was entered correctly into the electronic medical records system, and the pharmacy received the correct medication order, the AP reported. The IV bag was also labeled properly. After the pharmacy worker mistakenly filled Macpherson’s IV with rocuronium, a second employee did not catch the error while checking the vials of medication and the IV bag for the 65-year-old patient.” (via: Pharmacy Times).

As details of the tragedy continue to emerge, here’s what we know so far:

  • An infusion of fosphenytoin was ordered for the patient, presumably a piggyback.
  • Instead of fosphenytoin (anti-seizure med) the patient received rocuronium (a paralytic)
  • It is unclear at what point in the compounding process, if at all, the infusion was verified by a pharmacist. According to the article “a second employee did not catch the error while checking the vials of medication and the IV bag”. Not entirely sure what that means.
  • The infusion was hung
  • A fire alarm sounded
  • The nurse closed the patient’s door and didn’t check on her for 20 minutes. That was more than enough time for the drug to cause irreparable harm to the patient.

It is unclear what process was used to make the infusion, or what safety safeguards were in place. The real shame here is that there are any number of available technologies that could have prevented the error. Any of the semi-automated workflow management systems on the market today would have worked. Bar code scanning, gravimetrics, perhaps image assisted verification, etc. Take your pick.

According to an article from The Bulletin “To help prevent similar mistakes from happening, the hospital’s pharmacy has begun placing orange stickers on IV bags containing paralytic agents that indicate what’s in them. [The patient’s] IV bag had a blue sticker indicating it was a neuromuscular agent, which Boileau [Dr. Michel Boileau, St. Charles’ chief clinical officer], said both fosphenytoin and rocuronium are.” Not exactly sure how using orange stickers instead of blue is going to do much. Seems kind of silly. I think I’d start looking at something a little more aggressive. I’d also rethink my classification of both fosphenytoin and rocuronim as “neuromuscular agents”. I think I’d call fosphenytoin a hydantoin anticonvulsant and rocuronium a nondepolarizing neuromuscular blocker. They’re clearly not the same class of drug.

It will be interesting to see how organizations like ISMP and ASHP respond to this latest error.

Comments (2)