News and Opinion from Sisters, Oregon
News and Opinion from Sisters, Oregon
The family of Loretta Macpherson is grieving and the staff at St. Charles Medical Center is devastated after the Sisters woman died Wednesday as the result of a medical error.
Dr. Michael Boileau explained the tragic course of events to The Nugget on Thursday.
Macpherson had recently undergone successful brain surgery in Seattle and was recuperating at home.
"According to her son, she was feeling somewhat anxious at home and they were concerned as to whether the medications she was taking were correct and if she needed more medication," Dr. Boileau reported.
Macpherson's son Mark confirmed that the issue was anxiety.
"It was simply that," he said. "There was nothing else going on."
In fact, he said, his mother had recently had a CAT scan of her brain after the surgery to remove a tumor and "they said she was making a great recovery."
Macpherson was admitted to the hospital on Monday and doctors determined that she would benefit from being given an anti-seizure medication.
"Tragically, she was given the wrong medication," Dr. Boileau said.
The incorrect drug that was administered is called Rocuronium, which, Dr. Boileau said, is a paralytic used in surgery.
"I had left the room, my brother had left the room," Mark Macpherson told The Nugget. "I had actually left the hospital to run an errand and was going to come right back. My brother called and told me mom was in cardiac arrest and I needed to get back immediately. That was a shock because I'd just been told she was going home."
The hospital acknowledged the error. Dr. Boileau said that "senior leaders" talked to the family and explained to the best of their current information what had happened and "apologized to them - inadequate as that is."
The effects of medical error left Macpherson with irreversible brain damage. A medical team consulted with Mark and Pete Macpherson.
"We asked the question 'if this was your mother, what would you do?" Mark recalled.
Loretta died on Wednesday.
This is the first incident of a fatal medical error of this kind in the hospital's history.
Dr. Boileau noted, "We give these medications thousands of times a year, safely."
It is unclear as of yet why the normal checks and fail-safes failed in this case. The hospital is conducting a "root-cause analysis" of the case.
"There are many tiny steps involved in these processes," Dr. Boileau said. Those steps involve numerous people.
Mark Macherson told The Nugget that his understanding is that the error occurred in the labeling of the medication.
The Oregon Patient Safety Commission of the Oregon Health Authority and the national Joint Commission for patient safety have been notified. Additionally, Dr. Boileau said, "We decided yesterday (Wednesday) to involve the district attorney's office and the police department," not because there is a concern that there is any criminal act involved, but to bring in an outside agency to assure the community that "this incident is being investigated openly and completely."
"We've assured the family and we've assured that the community that we will be completely transparent about this," Dr. Boileau said.
All staff involved in the incident have been placed on paid administrative leave.
"They're being given support through the caregiver assistance program here at St. Charles," Dr. Boileau said.
"You can only imagine how devastating this is for someone who is involved in something like this," he said. "The whole thing is heartbreaking."
As hard as it is on the staff of caregivers, it is, of course, worse for the family.
"This is rough," Mark Macpherson said. "I've had some rough patches in my life... and this is the roughest thing I've ever gone through."
He said he's spoken to the media about the incident because he and his brother felt the community needed to be informed that this terrible thing had happened.
"This is a major issue," he said. "This is unacceptable. We wanted our community to know."
Jim Cornelius is editor in chief of The Nugget and author of “Warriors of the Wildlands: True Tales of the Frontier Partisans.” A history buff, he explores frontier history across three centuries and several continents on his podcast, The Frontier Partisans. For more information visit www.frontierpartisans.com.
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