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Painkiller mix-up at Butler Memorial Hospital puts patients in 'immediate jeopardy'

| Wednesday, Nov. 4, 2015, 11:31 p.m.

Staff at Butler Memorial Hospital placed patients in immediate jeopardy when they injected them with a narcotic seven times more powerful than the one prescribed by their doctors, according to a state Health Department report.

Hospital officials said no patients were harmed as a result of the errors, which occurred between Aug. 24 and 31.

“We immediately reviewed all available information regarding patients who may have been impacted. The review revealed nothing to indicate that anyone was harmed in any way,” hospital officials said.

The detailed inspection report, which was only recently made public, shows that a staffer mistakenly placed syringes prefilled with the pain killer Dilaudid in a dispenser partially filled with morphine sulfate. Hospital officials declared a violation known as “immediate jeopardy” when they identified that 18 doses of Dilaudid were administered to patients instead of the physician-ordered morphine sulfate, according to the report.

The hospital, as required under state and federal regulations, filed a plan of correction in which hospital officials said they did not find any evidence of patient harm resulting from the 18 separate medication errors.

Michael Cohen, president of the Institute for Safe Medication Practices, said the mix-up of the two drugs, morphine and hydromorphone, also known as Dilaudid, was a longtime concern.

“It's a well-known issue,” Cohen said, adding that the institute has published articles on the problem.

“Even today, there are health care professionals who don't understand the difference between the two drugs.”

But Cohen added that it's not as much of a problem as it used to be because of new technology, including the use of bar coding.

“We always tell people to read the label. Read the label,” he said.

Butler Memorial officials said they informed the state as soon as they became aware of the errors. The corrective action plan, which was approved by the state, included retraining and monitoring efforts to ensure that the error was not repeated.

According to the report, state inspectors discovered the errors during a Sept. 3 visit to the facility.

“On August 24, 2015, at 8:59 a.m., 15 prefilled syringes of Hydromorphone (Dilaudid) 2 mg were placed into another AcuDose compartment that already contained 10 prefilled syringes of Morphine Sulfate 2 mg,” the report states.

A minute later, three additional syringes containing Dilaudid were placed in another automated dispensing device that contained prefilled morphine sulfate syringes, the inspectors found.

According to the report, the staff missed a second chance to avert the errors when they administered the Dilaudid without verifying that the syringes contained the correct drug and dosage.

“The staff failed to ensure patient safety and meet the needs of patients,” the report states.

Hospital administrators said state health officials subsequently visited the hospital Oct. 30 and were satisfied with the improvements.

“We were alarmed by this unfortunate incident, and it has prompted us to examine every aspect of our medication distribution and administration process for opportunities to improve,” hospital administrators said in a written statement.

Walter F. Roche Jr. is a contributing writer for Trib Total Media. Reach him at

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