Would quick intervention have saved St. Charles patient?

Published 12:00 am Sunday, December 14, 2014

It’s unclear whether quick intervention, including CPR and the insertion of a breathing tube, could have saved the patient who died at St. Charles Bend on Dec. 3, two days after being given a medication that caused her to stop breathing.

Sixty-five-year-old Loretta Macpherson, of Sisters, went to St. Charles Bend’s emergency room with anxiety symptoms and concerns about the medications she was taking after recent brain surgery in Seattle. She was intravenously administered a paralyzing agent called rocuronium instead of the anti-seizure medication, fosphenytoin, that her physician had ordered, causing her to stop breathing and leading to cardiac arrest and irreversible brain damage.

The Deschutes County District Attorney’s Office said Friday it does not plan to file criminal charges related to the incident based on information received from the Bend Police Department, which investigated the case, said Deschutes County Chief Deputy Attorney Stephen Gunnels.

“From our perspective, unless the Bend Police Department finds reason to proceed with further investigation, I believe the investigation is complete,” he said.

No personnel decisions have been made regarding the three staff members involved in the case who are on administrative leave, Boileau said.

An internal investigation determined the error occurred in the hospital’s pharmacy, where the wrong medication had been inserted into Macpherson’s IV bag. It was labeled, however, as the medication she was intended to receive, so her caregivers did not know it was the wrong one.

Role of the IV

Allen Vaida, executive vice president of the Institute for Safe Medication Practices, a nonprofit dedicated to preventing medication errors, said it makes a difference that the medication was delivered through an IV, which caregivers can place and then leave the room while the medication is being administered, versus a shot, which caregivers must be present for while administering.

“If someone was standing there for the whole time, maybe they would have been able to save the patient, but that would be very hard to say,” he said.

It’s unclear how long Macpherson’s caregivers remained in the room with her after starting her IV medication. Dr. Michel Boileau, St. Charles’ chief clinical officer, said the hospital’s fire alarm went off about 20 minutes after the IV was placed, and he does not know whether caregivers were with Macpherson before the alarm sounded, or — if they were — for how long.

Once the fire alarm went off, a caregiver closed the door to Macpherson’s room, typically done during fire alarms to suppress a potential fire. About 20 minutes later, a caregiver checked on Macpherson, realized she had gone into cardiac arrest and performed resuscitation efforts. She was taken off life support the morning of Dec. 3 and died shortly thereafter.

Vaida, who read information on the St. Charles case, said the fact that caregivers left Macpherson alone in the room during the fire alarm does not strike him as problematic.

“That drug, the fosphenytoin, which she thought it was, gets administered quite a bit,” he said. “That would be something that probably wouldn’t be unusual at all for that nurse to hang the infusion, just watch for a minute or two and then leave the room. It’s very common.”

Boileau said Macpherson had already been taking a drug similar to fosphenytoin.

Lingering concerns

Others still have concerns about the case, including Dr. Ben Hopkins of Bend, who worked as an anesthesiologist for St. Charles for 22 years before retiring a few years ago.

Hopkins said he thinks it’s a bad practice to leave patients alone in a room while medication is being administered intravenously. Even if it’s something as innocuous as an antibiotic, he said people could still have deadly allergic reactions. If the door had to be closed, Hopkins maintains that someone should have been in the room with Macpherson.

“I just don’t think it’s wise to leave somebody in a closed room where they can’t call for help while a medication is being administered,” he said.

In Hopkins’ mind, that point is crucial, as he believes if CPR had been performed on Macpherson within five minutes, it could have saved her life. As an anesthesiologist, Hopkins routinely administered paralyzing agents before surgeries to relax muscles so surgeons could operate more easily. The patients had to be asleep or sedated and on a breathing machine, he said.

In this case, if the caregivers had seen that Macpherson was having trouble breathing, they could have started CPR and inserted a breathing tube, which would have been necessary for a half-hour to an hour until the medication wore off, Hopkins said.

“Now, they would not have known what happened, but the treatment stays the same,” he said. “Even though you don’t know the rocuronium caused it, the treatment stays the same, and that is that you breathe for her until she recovers.”

Hopkins also wondered why Macpherson’s vital signs weren’t being monitored using an alarm system. Boileau said her condition wasn’t serious enough to warrant doing so.

Bethany Walmsley, executive director of the Oregon Patient Safety Commission, said it’s hard to know how to react to the case without knowing how long or whether the patient was monitored after the IV was started, but standard practice would be to monitor the patient after administering a medication.

“It is very standard that most people will at least be there for the first several minutes to kind of check out how things are going, how the patient is reacting, et cetera,” she said.

Two representatives from the Institute for Safe Medication Practices visited the hospital last week to assess protocols and determine whether changes should be made, Boileau said. They determined that leaving the patient alone in the room during the fire alarm had no impact on the outcomes in her case, he said. Vaida confirmed that officials from the institute visited the hospital but said he could not release details about what they determined.

“We understand why, given the sequence of events, people might wonder about that,” said Lisa Goodman, a spokeswoman for St. Charles. “In our review of the sequence of events and also the ISMP’s review of the sequence of events, it was not determined to be a causative factor.”

Boileau said the caregivers in this case performed their duties appropriately under the assumption the patient had received fosphenytoin, which he said is not considered a “high alert” medication that would require monitoring after it’s administered.

Preventing future errors

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. Macpherson’s IV bag had a blue sticker indicating it was a neuromuscular agent, which Boileau said both fosphenytoin and rocuronium are.

The orange sticker is designed to prevent future errors, Goodman said.

“It will be less broad than neuromuscular agent, because that’s probably too broad,” she said.

Fire experts said the hospital staff followed proper protocols during a fire alarm, which include closing doors in areas that aren’t near the fire or smoke and “sheltering in place,” said Larry Medina, fire marshal and deputy chief of the Bend Fire Department. Closing doors is meant to stop the fire from spreading to other areas of the hospital, he said.

Had a fire come near the emergency room, all patients would have been evacuated, Boileau said.

Robert Solomon, division manager for building and life safety codes for the National Fire Protection Association, which develops fire safety rules for hospitals, said oftentimes hospitals will task one or a few caregivers with going back and checking on patients whose doors were closed during fire alarms, especially if there are high-risk patients who are on ventilators, for example.

There are no rules on how often caregivers should check on patients during fire alarms, but Solomon said it’s a good idea to do so.

“If we do have a fire alarm or if we have a drill, we want to make sure that somebody is designated to take some time out as appropriate to do some quick checks,” Solomon said.

Boileau said St. Charles does not have a standard procedure for caregivers checking on patients during fire alarms or when. Whether patients are monitored during alarms depends on their condition and what medications they’re receiving, he said.

In Macpherson’s case, monitoring during the alarm wasn’t deemed necessary.

“If anybody had known or suspected that she was getting a paralytic agent like rocuronium, it would have been a whole different scenario,” he said. “There would have been monitoring in the room. There would have been an anesthesiologist in the room. We would have had a tube in place to help her breathe. It would have been a completely different situation.”

— Reporter: 541-383-0304, tbannow@bendbulletin.com