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St. Charles Investigates Fatal Error

BEND, OR -- St. Charles Medical Center revealed more details surrounding the medical error that led to the death of a Sisters woman.  65-year old Loretta MacPherson died at the Bend hospital last week, after receiving the wrong medication.  Administrators held a press conference Monday, admitting a pharmacist grabbed the wrong medication, but put it in an IV bag that was labeled with the correct drug, so caregivers didn't immediately notice the mistake.


Chief Clinical Officer Dr. Michael Boileau says, 20 minutes after administering the drug, caregivers discovered MacPherson had stopped breathing.  He says this is the first time this has happened at St. Charles in the hospital's history. "Our management of medication- we have teams that are experts at this. We have been doing this for years at St. Charles and we have a good reputation, but we are acknowledging human error. But, it's also time to reevaluate all our processes."  Dr. Boileau says the three people involved with administering that drug are on administrative leave until a final investigation is completed.  


He says only one person is at fault for the mistake.  "What we'd like to make clear," said Dr. Boileau, "is that our pharmacists deliver thousands of doses every year, and we've been doing this safely for decades. We've never had an error. We believe our process is safer, but we are looking at every detail to see if there's a way to make them safer." The hospital is working to change some procedures to ensure nothing like this ever happens again.  



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