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Ohio Hospital Fires 23 After Fentanyl Overdose Deaths

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J.Adderton has 27 years experience as a BSN, MSN .

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48 Nurses and Pharmacists Reported to State Licensing Boards

A hospital in Ohio recently fired 23 physicians, nurses and pharmacists after 25 patients died from excessive doses of fentanyl. In addition, 48 nurses and pharmacists were reported to state licensing boards for their roles in the overdoses. You are reading page 11 of Ohio Hospital Fires 23 After Fentanyl Overdose Deaths. If you want to start from the beginning Go to First Page.

osceteacher has 15 years experience and specializes in Practice educator.

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On 7/30/2019 at 9:40 PM, MunoRN said:

It's certainly not the typical dosage required in a terminal wean, but I have given this amount and more (more commonly in morphine of opiate dose equivalents) during a terminal wean, this is based off established protocols.  In a terminal wean there is no "normal maximum dose", it's highly patient specific.

I don't know how it works in America but in the UK we use a book called the BNF which has the licensed doseing for the drugs, working outside of those is of course possible under certain instructions and policies but to work outside of that by a factor of 10 is absurd.

So a 'normal maximum dose' does exist in the UK, and its 200mcg for an unventilated patient, this does not mean that its a one size fits all, that wasn't what I was suggesting.

Reminds me of this case https://www.bbc.co.uk/news/uk-england-sussex-14709990 in my own hospital. They opened something like 15 vials of Digoxin, as soon as you open more than 4 or 5 you need to start looking heavily at your dosing imo.

Edited by osceteacher

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On 7/17/2019 at 5:14 PM, TriciaJ said:

This sounds like a badly-run hospital where physicians were allowed to run their own programs with minimal oversight and accountability.  The pharmacists and nurses who spoke out about this and refused to participate are long gone; we'll likely never hear from any of them.

The ones who stayed and played took a bigger chance than the ones who left; it doesn't seem to have paid off.  This is the danger of group-think and thinking there is safety in numbers.

Yes, if they even realized that dosages were out of normal range.

 

I once had a pt with Ca who was getting MS04 300 mg. q 4-6 h.

300

not 30

I had never seen a dose like that.  I did double check with the doctor, got put down for my concern, but doc verified that the dose was 300.,  As we used to say, pt never turned a hair.  (She was fine, tolerated that dose unremarkably.)

Edited by Kooky Korky

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Asystole RN is a BSN, RN and specializes in Vascular Access, Infusion Therapy.

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12 hours ago, Kooky Korky said:

Yes, if they even realized that dosages were out of normal range.

 

I once had a pt with Ca who was getting MS04 300 mg. q 4-6 h.

300

not 30

I had never seen a dose like that.  I did double check with the doctor, got put down for my concern, but doc verified that the dose was 300.,  As we used to say, pt never turned a hair.  (She was fine, tolerated that dose unremarkably.)

You are operating under the assumption that these interventions were accidental in nature. From the bits and pieces of the story this sounds like a palliative sedation program that lost touch with the goals and ethical practice of palliative sedation. 

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subee has 48 years experience as a MSN, CRNA and specializes in CRNA, Finally retired.

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On 8/5/2019 at 11:33 PM, Kooky Korky said:

Yes, if they even realized that dosages were out of normal range.

 

I once had a pt with Ca who was getting MS04 300 mg. q 4-6 h.

300

not 30

I had never seen a dose like that.  I did double check with the doctor, got put down for my concern, but doc verified that the dose was 300.,  As we used to say, pt never turned a hair.  (She was fine, tolerated that dose unremarkably.)

Yes, but you had some kind if history on that oatient and knew her tolerance.  I'm not sure these nurses had that kind of comfort level in Ohio or else they wouldn't have questioned the order.   Maybe this loose cannon was switching the patients from MS04 to Fentanyl.  Not enough info but the dr. sounds like a nut .  And why would an anesthesiologist be working the night shift in a palliative care unit? 

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Luchador has 5 years experience as a CNA, EMT-B.

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On 7/30/2019 at 6:18 PM, KalipsoRed21 said:

I probably would have reviewed with my supervisor and if s/he said it was okay I would have assisted in this order. I do fundamentally agree that these orders are more in the doctor’s realm of decisions than mine. And when a I disagree with both the doctor and the supervisor I do attempt to pull family aside and express my personal concerns.

I am curious as to what you think the possible outcomes are of giving a patient an IV paralytic and then extubating the patient. 

I am grateful for your thoughts because they illustrate how a go along mentality could cause a nurse to lose his license or even end up behind bars.

 

 

Edited by Luchador

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KalipsoRed21 is a BSN and specializes in Currently: Home Health.

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On 8/3/2019 at 7:27 PM, subee said:

2000mcg Fentanyl would require breaking open 20 glass ampoules of Fentanyl (in the smaller size) so that's a red flag.  Don't need a supervisor to tell you that and if he/she went along with it raise your arms high and scream.  This should have been taken up the medical chain of command.

Okay, so here’s my deal about the dosage. I have been ordered to give, in the ER, very high and unusual doses of medications. I have frequently overridden medications on the floor and in the ER because “patient care first and we need this drug now!” You think I had time to look up all of these weird doses to double check the MD before I administered? Uh, no. I find that a lot of this comes with how much one trusts the physician they are working with. As I’ve said before I’ve given dose of steroids that is 200x higher than what what I “commonly” give. I asked the doctor, he gave what I thought was a reasonable answer as to why the dose was so high, I administered it. I had worked with him a year and he seemed like a good physician. He was actually. 

I have no disagreements that this physician was not providing good care to his patients. What I do find terribly aggravating is the assumption that these 48 nurses and pharmacists should have “know better”. I’m not saying that a couple in there should have. What I’m saying is that this doctor wasn’t maybe the “*** doc”. That when questioned regarding his order he may have had a reasonable answer. How long had these nurses and pharmacists been practicing? If the pervasive line of thought is that a 1-2 year old nurse would not be at risk of following these orders if given a reasonable “sounding” explanation by the doctor....or threatened by the doctor, then I just think that is really naive and ignorant to how lacking nursing school education is and places an incorrect amount of responsibility on them to refuse without any back up.

Furthermore, it also says in this article that nursing/pharmacy staff HAD brought up concerns about this physician more than a YEAR earlier. If you are on staff and you know these concerns have been ‘taken all the way up the chain” but nothing has happened to the doctor, why is it so unbelievable that these 48 nurses and pharmacists would go, “Well we have taken our concerns up the chain. Nothing happened so we must have been wrong.” 

Subee, you have an MSN and are a CRNA, of course you have a great understanding narcotics. You have an additional 4 or more years of education regarding sedatives. Can you not remember a time when you were a nurse before this extra education that you did something potentially seriously wrong because that’s how it had been explained to you but with the extra education you now know it was wrong?

The average BSN has 4 years of school and 2 of it is actual nursing education. Doctors have 4 years of medical school and 3-7 years of residency before they are an MD. This article says this was a doctor making these orders. Not a resident, which I would totally question especially in July. But there is a LARGE knowledge gap between doctors and nurses. Yes that gap gets smaller the longer a nurse practices, but it never goes away completely. There is a minimum of 7 years in education gap between MDs and nurses. So you expect a 10 year old to have the same ability to reason out and refuse an adult direction the same as a 17 year old?  If that were a reasonable expectation then we would have a whole lot fewer child molesters in the world because the 10 year olds would speak up sooner. 

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KalipsoRed21 is a BSN and specializes in Currently: Home Health.

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On 8/8/2019 at 4:40 PM, Luchador said:

I am curious as to what you think the possible outcomes are of giving a patient an IV paralytic and then extubating the patient. 

I am grateful for your thoughts because they illustrate how a go along mentality could cause a nurse to lose his license or even end up behind bars.

 

 

I understand what a paralytic is and how it affects the respiratory system. Have you ever been in a code and the patient been worked over for 45-60 minutes and the MD call the code when the patient was in v-fib? I have. You think I should do what? Continuing running the code when the MD called it after an hour? Do I know what exact circumstances that I would agree to administer a paralytic and pull a tube? No, but I’m not willing to say that the situation arising is IMPOSSIBLE or that it would NEVER be reasonable to follow such an order. At a glance the nurse in the article who did this sounds like an idiot. But as I’ve said, news reports are sensationalized, parts of the story are missing, and that I don’t expect a hospital review board to ever find themselves at fault. Thus I’m not willing to just say, “Well thank God all these nurses got their licenses pulled, it is obvious they were poor at their profession! Good riddance!”

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NRSKarenRN has 40 years experience as a BSN, RN and specializes in Vents, Telemetry, Home Care, Home infusion.

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Update:

2 largest settlements yet add $9M over deaths tied to doctor
 

Quote

 

...The Ohio hospital system that found an intensive care doctor ordered excessive painkillers for about three dozen patients who died has reached settlements totaling $9 million in lawsuits over two deaths, which would be the highest known payouts so far in the related wrongful-death lawsuits.

Mount Carmel has agreed to roughly $13.5 million in settlements so far, including two filed within the past week that still must be approved by a judge.

The hospital system previously settled at least seven other cases, plus two that didn't involve lawsuits, for a total of nearly $4.5 million . Those settlements ranged from $200,000 to $700,000, with patients' families typically getting two-thirds or less of the money and the rest going to lawyers and court costs.

The families and the lawyers aren't commenting on the settlements, citing related confidentiality restrictions. About 20 lawsuits are still pending....

 

 

 

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Janice F specializes in Quality Management.

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 Don't ignore your gut. It is our knowledge of drug actions and familiarity with the usual dose that alerts us to something not being right about an order.

Do not succumb to or create work-arounds. In the long-run, there is NEVER a benefit.

Periodically review the ANA Code of Ethics and Standards of Practice. I found that reviewing them (and hanging posters of them in my work area) were vital to my practice.

If there is a problem with a process consider doing the following:

  1. Write down when it happened, what happened and consequences.
  2. Keep track of your actions and responses in a notebook/binder/your phone..somewhere. You may need to refer to them if results are slow to come.
  3. If something requires your immediate refusal or may cause harm to patients then it is very important that you be specific about the conflict and consider doing the following;  call the MOD, call the nursing supervisor on duty, call the union rep, alert the Ethics committee,  complete an incident report, call your quality management HL (can be anonymous), call the Joint Commission HL (can be anonymous), email your NM and cc the risk manager.

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Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

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On 7/18/2019 at 2:57 AM, OUxPhys said:

It sounds like these are all reasonable actions. Bypassing safety measures that were in place. Not questioning MD orders by both the RN and Pharmacist (seriously, 2,000 mcg of Fentanyl and 10 mg of Dilaudid?? Hospice pmts dont even get that much at one time).

However, what really angers me is they punish the RNs and pharmacists, lower level managers (rightfully so) yet several higher ups got to "step down" and "retire". Unreal. 

The highest dose i ever saw working in palliative care was 600mcg fentanyl in a syringe driver running over 24 hours. 

 

On 7/19/2019 at 7:09 PM, TriciaJ said:

Funny how when they find out they can't intimidate you (and you threaten to blow the whistle) they back off.  This is why bullies need to be stood up to, not backed down from.

Oh hell yes

I was asked to incorrectly document something. I just politely nodded and proceeded to document what happened, not what they wanted me to put. 

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Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

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On 7/21/2019 at 4:05 AM, sassyrn333 said:

. Under similar circumstances I imagine most of you would make the same mistakes. 

 

Absolutely not

Even when I had to put 600mcg fentanyl into a syringe driver for a palliative patient, who was dying in the community you can bet I double and triple checked that order

If a doctor charted 2000mcg to be given in an ICU setting, any nurse who does not seriously question that order and proceeded to give it, IMO is incompetent, dangerous and should be struck off 

Yes, doctors made mistakes, or in cases like this chart deliberately high doses, a nurse has a responsbility to know the safe dosing ranges and question if need be refuse to give if they feel it is unsafe

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Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

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On 7/21/2019 at 4:48 PM, KalipsoRed21 said:

 

The nurses and pharmacists should get no reprimands. It is a nurse and pharmacist’s job to follow the orders of the physician.

 

 

***

its the nurses job to advocate for the best wellbeing of the patient. 

A few weeks ago I had a patient showing all the signs of a CVA. We rung the oncall house surgeon who told us "I will be there when I've had my tea" 

The condition continued to deteriorate and bluntly I ended up asking the senior doctor who was on the  ward to review the patient, and low and behold the patient was transfered to an acute stroke ward where he recieved a clot buster, and fortunately came through the experience with not many lingering side effects

No half way competent board of nursing would disipline a nurse for advocating for the best welfare of the patient. They will however bust metaphorical balls if the nurse could have done something differently but didnt 

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