Pharmacy error led to Oregon patient death

Patient Safety Monitor Insider

December 10, 2014

The death of a hospital patient last week in Bend, Oregon occurred because a pharmacy worker inadvertently filled an IV bag with the wrong drug, according to a report from ABC News.

According to the report, a series of human errors at St. Charles Medical Center started when the patient was given a paralyzing agent typically used during surgeries instead of the anti-seizure medication that was prescribed for her. While the drug, fosphenytoin, was correctly entered into the electronic medical records system and the hospital's pharmacy received the correct medication order, an investigation found that a pharmacy worker inadvertently filled the bag with the wrong drug, rocuronium.

Then, shortly after the medication was administered, a fire alarm led a staff member to lock the door of the patient’s room for safety protocols, leaving her unattended for 20 minutes. When staff came back to check on her, she was in cardiac arrest, the report said.

Three employees were placed on administrative leave after the incident, and the hospital has instituted a “safety zone” in its pharmacies so workers can complete medication verifications with fewer distractions, the report added.