St. Charles Health System

St. Charles Health System
not-for-profit healthcare,
not-for-profit hospitals
Industry Healthcare
Headquarters Bend, Oregon
Website stcharleshealthcare.org

St. Charles Health System, Inc. (SCHS) is a four-hospital network and healthcare company in Central Oregon. Headquartered in Bend, the system owns and operates the St. Charles medical centers in Bend, Redmond, Madras and Prineville. SCHS is a private, not-for-profit Oregon corporation and with more than 3,000 employees it is the largest employer in the region.[1]

History

Then Mountain View Hospital in Madras entered into an agreement with SCHS to provide management services for the hospital in 1998.[2] In 2001, Redmond's Central Oregon District Hospital became a part of the system, with St. Charles then taking over the operations of Prineville's hospital in 2008.[2] Mountain View Hospital then merged into the system in 2013 and became St. Charles - Madras.[2]


Notable events


Loretta Macpherson Death -


On December 1st, 2014 a local area resident, Loretta Macpherson was admitted to the St. Charles Medical Center's Emergency Department to be seen for anxiety. Macpherson was suffering from anxiety several days after a successful brain tumor removal at The Swedish Medical Center in Seattle, Washington. When Macpherson informed doctors at the St. Charles Medical Center ER department of her anxiety issues, Macpherson's physician ordered an anti-seizure medicine. The attending physician put the order into the St. Charles Pharmacy Department and the order was received correctly, however the pharmacy inadvertently prescribed Macpherson the wrong medication. Instead of the correct medication of Fosphenytoin, the Pharmacy Department mislabeled an IV bag of Rocuronium, a paralyzing agent, and sent it to the Emergency Department for administration to Macpherson. The mislabeled drug was administered to Macpherson causing Macpherson to stop breathing and to go into cardiopulmonary arrest. She experienced an anoxic brain injury and was put on life support. Macpherson was taken off of life support and passed away 3 days later.[3] [4]


The St. Charles Health System later put out a series of press releases admitting fault to the major medication error, with the clinical chief officer Dr. Michael Boileau stating; "We believe that a tragic medication error occurred, and that mistake, that error, has caused her death. This appears to be a misidentified medicine. We thought we are going to give one medicine,and we gave another medicine."[5][6] The medication error resulting in Macpherson's death sparked extensive media coverage throughout the nation and worldwide.[7][8][9][10][11][12]


On September 22nd, 2015 it was discovered that a Federal report by the U.S. Centers for Medicare & Medicaid Services completed an investigation into the December 1st, 2014 event revealing that the medication mislabeling was not the only major error that allegedly led to Macpherson's death. The Federal report states that the hospital received three violations including Patient Rights, Pharmaceutical Services and Nursing Services.[13] Among allegations, the Federal report states that the St. Charles Emergency Room Physician overseeing Macpherson had ordered the attending nurse to provide continuous cardiac monitoring and continuous pulse oximetry monitoring for the patient prior to medication being administered. Dr. Michel Boileau, St. Charles’ chief clinical officer, was quoted in December saying that the staff determined that monitoring Macpherson’s vitals was not necessary. "“There wasn’t any indication to do so, Her management and the degree of surveillance and observation that she was given was appropriate for the medicine that the staff believed she was receiving.”[14] The Federal CMS report includes information about the hospitals policy's to monitor "response to any medication, and particularly one that is being given for the first time, is monitored by nursing staff for therapeutic or adverse effects. This monitoring includes, but is not limited to: Vital signs, lab values, blood levels, therapeutic ranges, and the patient's perceptions. Documentation of patient's response to all PRN medications is required."[15] The Federal report also includes instructions from www.drugs.com to monitor patients closely[16] when receiving Fosphenytoin via IV along with The 2013 Nursing Handbook.


The report concludes that the nurse handling Macpherson acknowledged the doctors order to hook up pulse oximetry monitoring but then discontinued it without an order to do so. The report further acknowledges that the nurse never hooked Macpherson up to cardiac monitoring.[17] The report ends with acknowledging that Macpherson's room was located directly across from the nurses station and the Chief Nursing Officer states "If the patient had been on cardiac monitoring as ordered, an audible alarm would have sounded and alerted staff at the nurse's station when the patient's cardiac status declined."


The incident is under investigation by Deschutes County District Attorney John Hummel.[18]

See also

References

  1. ↑ "Madras hospital seeks acquisition by St. Charles". KTVZ.COM. July 25, 2012. Retrieved 1 January 2014.
  2. 1 2 3 Hagemeier, Heidi (January 10, 2013). "Madras hospital is now St. Charles". The Bulletin. Retrieved 1 January 2014.
  3. ↑ KTVZ News (December 3, 2014). "'Tragic error': St. Charles probing wrong-drug death".
  4. ↑ The Bend Bulletin (December 4, 2014). "Error at St. Charles Bend results in patient’s death".
  5. ↑ The Bend Bulletin (December 5, 2014). "St. Charles Bend admits mistake led to patient death".
  6. ↑ KTVZ News (December 8, 2014). "Wrong drug put in IV bag led to fatal Bend hospital error".
  7. ↑ United Kingdom Daily Mail News (December 9, 2014). "patient, 65, died at Oregon hospital after nurse filled IV bag with the WRONG drug".
  8. ↑ Canadian Business News (December 4, 2014). "Oregon hospital says patient died after getting paralyzing agent instead of anti-seizure drug".
  9. ↑ (Iraq News) Face Iraq (December 9, 2014). "Oregon brain surgery patient dies after being given wrong drug".
  10. ↑ Australia News One Page News (December 5, 2014). "St. Charles Probes Death".
  11. ↑ Fox News. "Pharmacy error led to patient death, hospital confirms".
  12. ↑ CBS News. "Hospital medication error kills patient in Oregon".
  13. ↑ "U.S. Centers for Medicare & Medicaid Services Federal Report St. Charles January 26th, 2015".
  14. ↑ The Bend Bulletin. "Federal report: St. Charles patient not monitored before death".
  15. ↑ VIOLATION: Nursing Services - Section 3. "U.S. Centers for Medicare & Medicaid Services Federal Report St. Charles January 26th, 2015".
  16. ↑ "Fosphenytoin Dosage Form: IV".
  17. ↑ "VIOLATION: Nursing Services - Section 5.".
  18. ↑ KTVZ News (September 22, 2015). "St. Charles patient death spurs federal investigation, citation".


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