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    Report faults Children’s Hospital for medication errors

    Advance for Spotlight- Boston Ma. 9/24/08 Exterior of Children's Hospital. Jonathan Wiggs/Globe Staff Section;Spotlight Reporter: :slug:
    Jonathan Wiggs/Globe staff/file 2008
    Boston Children’s Hospital changed its procedures for treating sepsis patients and for administering a drug, Propofol, averting discipline by federal regulators.

    Three patients at Boston Children’s Hospital suffered from medication errors in 2017, including one who waited hours for an antibiotic and later died, according to a state and federal inspection report.

    The mistakes, which occurred between January and November and involved two drugs, prompted regulators to threaten the hospital with potential termination from the federal Medicare program. They show that even with safety advances in medication administration, drug errors are still a serious problem for hospitals.

    In the case of the patient who died, caregivers ordered an antibiotic, Zosyn, at noon, but a nurse did not administer the drug until 14 hours later at about 2 a.m., according to the report. The patient died two days later after developing sepsis, a widespread infection that, like a heart attack or stroke, requires immediate treatment.

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    Two other patients received overdoses of the anesthetic Propofol. After the first overdose in January of last year, hospital leaders recommended a clearer procedure for measuring doses. A pharmacist interviewed by inspectors said those recommendations “never materialized,’’ according the report. Ten months later, a doctor gave an overdose to another patient using the same potentially confusing procedure.

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    That second patient stopped breathing and was resuscitated, and hospital executives said both overdose patients ultimately recovered. The inspection report does not include patient names and ages.

    This spring, Children’s adopted improvement plans for treating sepsis patients quickly and for administering Propofol accurately, averting discipline by the federal Centers for Medicare & Medicaid Services.

    Dr. Jonathan Finkelstein, the hospital’s chief patient safety and quality officer, declined to discuss specific cases because of patient confidentiality rules. While the hospital is a national leader in its consistent focus on patient safety, he said, “we are not perfect.’’ When there is a misstep “we set out the very next day to improve care,’’ Finkelstein said.

    Medication mistakes are the most common type of medical error in hospitals. The Institute of Medicine, a nonprofit organization that advises the government, has estimated that an average of at least one drug error per patient occurs each day in hospitals. While not all of these mistakes cause harm, the organization said at least 1.5 million Americans are injured each year by drug treatment.

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    In Massachusetts, which tracks only the most serious errors, hospitals reported 47 medication errors that killed or injured patients in 2016, the most recent year of available data.

    The Medicare and Medicaid agency threatens hospitals with termination from the public insurance program when it finds substantial violations of rules, but the agency rarely follows through on that threat.

    The medication errors at Children’s were serious not only because of the harm or potential harm to patients, but because they revealed possible underlying flaws in procedures. Inspectors said in their 46-page report that the hospital failed to completely analyze the errors and thoroughly correct the conditions that caused them. Their findings were based on visits to the hospital over five days in November and December.

    The critically ill patient was admitted to Children’s in March 2017 and required a breathing machine, a machine to oxygenate and pump the blood, and dialysis. After the antibiotic was prescribed, the patient’s nurse erroneously thought someone had given a verbal order to hold the medicine for further test results.

    After the patient died, hospital leaders e-mailed an alert to doctors and nurses in the intensive care unit where the patient was treated reminding them that all medication orders should be written — except in an emergency. Inspectors faulted the hospital for not alerting caregivers hospital-wide about the rule, a step Children’s has since taken. The hospital also said that changes to orders must be in writing to avoid confusion.

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    Finkelstein, the chief patient safety officer, said the hospital also has implemented a new protocol that triggers a sepsis evaluation for any patient whose condition deteriorates. Almost 7,000 children nationwide die each year from the catastrophic infection, more than the number who die of pediatric cancers, according to the nonprofit Sepsis Alliance in San Diego.

    In the case of the first Propofol overdose in January 2017, a physician in training gave a patient 50 milligrams of the anesthetic instead of the intended dose of 15 to 30 milligrams. A nurse had filled a syringe with more than one dose, but the doctor did not know that.

    In April, a hospital committee that oversees pharmacy issues recommended adopting a new policy requiring that each syringe contain just one dose of Propofol based on the patient’s weight.

    That change never occurred, and 10 months later, in October, a physician in training gave a patient 60 milligrams of Propofol instead of 10 milligrams as intended. The patient’s blood pressure plummeted and breathing stopped, but the patient was resuscitated. As of Nov. 24, the change apparently had still not been implemented, according to the inspection report.

    Children’s has since issued a hospital-wide alert stating that when medications are handed off to another clinician, only a single, labelled, weight-based dose can be prepared in a single syringe.

    Dr. Robert Wachter, a professor at the University of California San Francisco and a patient-safety expert, said academic medical centers are bureaucracies with layers of committees.

    “The group at the front line may say this is a sensible solution, then it may go to people up the line and they have a challenge with it that the front line people didn’t see,’’ he said. “Big complex organizations sometimes don’t act with the urgency they should. They think it’s important to fix it but that it’s not going to happen again.’’

    But “if what you are doing is potentially fatal if you get it wrong, you have to have a way to move it through the system more quickly,’’ he said.

    Finkelstein agreed that implementing the dosing change “took longer than it should have in retrospect. Now we have a system to make sure all action items get implemented immediately.’’

    In its 63-page improvement plan, Children’s acknowledged “the need to focus additional attention in our responses to specific events,’’ including “the potential of a similar event occurring in another area.’’

    Despite the growing attention to preventing drug errors in hospitals, experts said it’s hard to know whether they are decreasing.

    “A lot of times with patient safety, when you start to focus on an issue, you will see your reports go up,’’ said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, a state agency that collects and analyzes safety data.

    Wachter believes technology, from computerized medication-dispensing machines to bar codes on patient wristbands, has made medical care far less risky for patients. “There is no question that it is safer for all sorts of reasons,’’ he said.

    Liz Kowalczyk can be reached at kowalczyk@globe.com.