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Hospital medication error kills patient in Oregon

A hospital in Bend, Oregon, says it administered the wrong medication to a patient, causing her death.

Loretta Macpherson, 65, died shortly after she was given a paralyzing agent typically used during surgeries instead of an anti-seizure medication, said Dr. Michel Boileau, chief clinical officer for St. Charles Health System.

He said Macpherson stopped breathing and suffered cardiac arrest and brain damage.

Macpherson came into the ER two days earlier with medication dosage questions after a recent brain surgery.

Three employees involved in the error have been placed on paid leave. The organization is conducting an investigation, but doesn't yet know how the error occurred, Boileau said.

The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient.

"We're looking for any gaps or weaknesses in the process, or to see if there has been any human error involved," Boileau said.

The hospital notified the Deschutes County district attorney, who did not immediately return a call for comment.

According to the Bend Bulletin, the doctors determined Macpherson needed an intravenous anti-seizure medication called fosphenytoin, but instead accidentally administered rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage. The hospital took Macpherson off life support Wednesday morning.

The patient's son, Mark Macpherson told the newspaper he'd recently moved to closer to care for her. "We didn't get the answer for a couple of days about what had happened, but when they first told us, it was pure anger," he told the paper, adding that he wasn't sure if the family planned to pursue legal action.

Boileau told the newspaper this was the first time the hospital has dealt with a situation like this. "We are in the process of that analysis right now. Before we say exactly what happened, we're going to make sure we're accurate about. We do know there was a medication error. We acknowledge that. It's our mistake."

Studies show hundreds of thousands of people die every year in the U.S. due to hospital errors, although it's not clear how many of those cases involve drug mix-ups like this one. A report published in the Journal of Patient Safety last year says the number of deaths due to preventable hospital errors ranges from 210,000 to 400,000 people each year. Earlier this week, the Department of Health and Human Services reported that such errors declined by 17 percent between 2010 and 2013.

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