- Associated Press - Thursday, November 5, 2015

BUTLER, Pa. (AP) - A hospital injected patients with an addictive narcotic painkiller that was seven times more powerful than had been prescribed by doctors, according to a report released by the state.

A Health Department report stated that a staff member at Butler Memorial Hospital mistakenly placed syringes prefilled with the painkiller Dilaudid in a dispenser that was partially filled with morphine sulfate, the Pittsburgh Tribune-Review reported (https://bit.ly/1MBJsmO) Wednesday.

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

Hospital officials said patients were in “immediate jeopardy” when 18 doses of Dilaudid were given instead of the morphine sulfate between Aug. 24 and Aug. 31.

But the hospital says no patients were harmed as a result of the mix-up, and it filed a plan of correction. State health officials visited the hospital on Oct. 30 and were satisfied with the improvements, administrators said.

“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 statement.

Michael Cohen, president of the Institute for Safe Medication Practices, said confusing the two drugs is a “well-known issue” and that they’ve published several articles on it.

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

New technology, such as bar codes, has helped mitigate the problem, he said, but that they always tell people to read the labels.


Information from: Pittsburgh Tribune-Review, https://pghtrib.com

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