PORTLAND – The death of a hospital patient who was given the wrong medication occurred because a pharmacy worker inadvertently filled an IV bag with the wrong drug, officials at an Oregon hospital say.
The mistake was one of several revealed Monday that led to the death of Loretta Macpherson, who had gone to the emergency room at St. Charles Medical Center in Bend.
Officials at St. Charles Health System said Macpherson, 65, was given a paralyzing agent typically used during surgeries instead of the anti-seizure medication that was prescribed for her last week.
Hospital officials said the drug prescribed by the physician, fosphenytoin, was correctly entered into the electronic medical records system and the hospital’s pharmacy received the correct medication order.
The IV bag also was correctly labeled. But the hospital’s internal investigation revealed that a pharmacy worker inadvertently filled the bag with the wrong drug, rocuronium. A second worker then reviewed the vials of medication and the IV bag without catching the error.
Shortly after the medication was administered to Macpherson in the ER, a fire alarm led a staff member to lock the door of Macpherson’s room “to protect her from potential fire hazards.”
Health system spokeswoman Lisa Goodman said Macpherson was in the room for about 20 minutes before a nurse returned to check on her. By that time, the patient had suffered cardiac arrest.
Though doctors were able to resuscitate Macpherson, she had suffered brain damage. She was taken off life support two days later.
Three employees involved in the error have been placed on paid administrative leave.
Dead orca pregnant, near labor
SEATTLE – The necropsy on the endangered orca found dead off Vancouver Island showed it was pregnant with a full-term fetus, and that someone removed several teeth from the dead killer whale before it could be examined.
Experts had speculated the death may have arisen from birth complications.
A death examination completed on the calf Monday revealed it was a female whale and close to full term, said Paul Cottrell, Pacific marine mammals coordinator for the Canadian Department of Fisheries and Oceans.
Cottrell also said someone removed several teeth from the animal. Four teeth were cut at the gums, and three others were damaged. It’s illegal to possess part of an endangered animal.
Soil problems vex tunnel work
SEATTLE – There are more problems for the Highway 99 tunnel project beneath downtown Seattle, as engineers study whether settling soil means work should be altered on a pit being dug to reach a stalled digging machine known as Bertha.
Tests over the weekend showed the settling around the pit is uneven, the Department of Transportation said.
No differential settling, which is potentially risky for structures, was detected on the Alaskan Way Viaduct, which remains safe for travel, the department said Monday.
The settling near the pit is apparently the result of groundwater pumped out by Seattle Tunnel Partners as it digs a 120-foot access pit to reach and replace the damaged head of the boring machine.
Bertha overheated and stopped a year ago. It has drilled about 10 percent of the way into a planned 2-mile tunnel to replace the viaduct.
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