Ohio Hospital Fires 23 After Fentanyl Overdose Deaths
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.
On July 12, 2019, Mount Carmel Health System in Columbus, Ohio, announced the firing of 23 employees, including physicians, nurses, pharmacists and managers. The terminations were related to the deaths of 29 critically ill patients from fentanyl administered during hospitalization that resulted in overdoses. Additionally, the hospital’s chief executive officer announced he would be stepping down and the executive vice president and chief clinical officer would retire in late September. These events are centered around the alleged criminal activity of William Husel, DO, an intensive care physician practicing at Mount Carmel from 2013 until the end of 2018.
The Details
Dr. Husel started working at Mount Carmel in 2013 and during his employment, potentially fatal doses of fentanyl were ordered and administered to 29 of his patients. According to the hospital’s internal investigation, this included five patients whose conditions could potentially improve.. The investigation also concluded six additional patients were overdosed on fentanyl, however, it was not likely the cause of their deaths.
The affected patients were critically ill and their families had requested that all life-saving measures be stopped. While the fentanyl was ordered as a comfort measure, the doses far exceeded the amount needed for palliation. Patients received fentanyl doses as high as 2,000 micrograms, midazolam as high as 10 milligrams and several patients were also given dilaudid doses up to 10mg.
Dr. Husel has been charged with murder in the deaths of 25 patients and has entered a plea of not guilty.
Failed Safeguards
Although Dr. Husel provided the order, physicians do not practice in silos. Others played a part, many unknowingly, in administering the excess doses and safeguards to protect patients were either ignored or did not exist. These include:
A formal report was received related to Dr. Husel’s care on October 25, 2018, however, Dr. Husel was not removed from patient care until November 21, 2019. During this time, three patients died from potentially fatal doses of medication ordered by the doctor.
Layers of medical protocols were overlooked or did not exist.
Medications obtained through electronic drug dispensing cabinet by nurses using the override function that avoided warnings
Orders verified by pharmacists after administration and some overridden doses bypassed the pharmacists altogether.
No system in place to audit or track the amount of medications ordered, including fentanyl, prior to the first formal complaint in October 2018
Instances of a nurse or pharmacist raising questions about the ordered doses, but the concerns did not make it up to the higher level administrators.
Mount Carmel Health System reported 48 nurses and pharmacists to state licensing boards. The reported individuals face disciplinary actions ranging from reprimand and fines to permanent revocation.
Response By Ohio Board of Nursing
In March, the Ohio Board of Nursing sent letters to 25 nurses who administered the drugs ordered by Husel. The letters outlined state law violations based on the nurse:
Knowing or should have known the drugs would be harmful
No documentation orders were questioned or that they consulted with others involved in the patient's care.
The nursing board also questioned the use of paralytics without nursing documentation to support the clinical need. In one case, the nurse failed to question the removal of a breathing tube after a paralytic had been administered.
Corrective Actions
To address gaps in standardized procedures, policies and safeguards, Mount Carmel Health Systems implemented a detailed action plan. Examples include:
Adding protocols to set maximum doses for pain medications in the electronic medical record
Implementing an escalation policy for deviations in pain administration protocols:
Restricting the ability to bypass pharmacy review of medication orders
Increasing staff education on end of life care
Implementing initiatives to ensure patient medication safety
Civil Suits
Numerous families brought civil actions for the loss of loved ones given the excessive fentanyl doses. To date, reported settlements range from $200,000 to $700,000 and total 4.5 million.
What are your thoughts on the events at Mount Carmel? Where do you see safeguards failing in your area of practice?
But no where in there did it say it was okay for me to refuse to preform an order.
And no where did it say that you are to carry out every order without question. We are not robots. To follow your line of thinking why do we even study pharmacology or anything beyond how to do basic nursing tasks? We should just do what the doctor says regardless of how wrong it might be? Is that how you practice?
And FTR it's "perform" not "preform". I wouldn't have pointed this out but it is a repeated error in your posts.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
6 hours ago, she244 said:
While working in the ER I have refused to give a medication ordered by a Physician who was called to come in to admit a patient but did not want to come in. He asked me to look in the PDR for the correct dose so he could order it. The ER Physician heard the conversation and got involved. What the Physician had ordered was 3 times the amount that should have been ordered. I refused to give the medication. The Nursing Supervisor was called and ended up taking over care of that patient as I let her know between the admitting doctor, ER physician, Pharmacy, poison control who was called I refused to be a part of it. I was sent home. Met with the Nursing director, Director of the Hospital, Pharmacy Director was there. After being threatened with dismissal. I let them know I would gladly go public with the facts that if a competent Physician had came in to the Hospital and did admit ordered as usual I may have followed his ordered but I refused to work out of my scope of practice to look up medication in the PDR to give a Physician the dosage of a medication to treat a life threatening over dose. Ended up staying 11 years in the ER.
Well this is what I’m talking about. Of course you would not look up a PDR dose and basically come up with the dose for the order. Coming up with the dose IS out of your scope of practice. Do I follow orders ‘blindly’ no. I question orders, I would still complete a WRITTEN order from a physician who was on staff for 2000mg of Fentanyl after I expressed my concern about the dose.
Look nursing is sort of like a parent-child relationship in some ways. Or being a soldier in the military. I may express concern about doses that seem off to me and clarify, but if I’m ordered to do it, and the patient isn’t refusing, then I proceed with the order. Doctors go to school 4-7 years longer than we do for the express purpose of being able to come up with these orders. Orders are not called suggestions for the sole fact that they are meant to be followed.
Unfortunately, "the doctor told me" is not a suitable defense in any state.
States may slightly vary but if a reasonable prudent nurse in that situation should have expected or suspected patient harm from a medication you are expected to act. That action could be holding the medication or taking other preventative interventions to ensure the patient was safe but nonetheless, action needs to be taken.
I again cast doubt that mistakes were made in this case. I do not think it was a case of, "the doctor told me" or of ignorance. I strongly suspect these were cases of palliative sedation and someone objected resulting in an investigation that highlighted other cases of palliative sedation.
Problem with palliative sedation is that it is a very sensitive and tricky procedure requiring excellent charting, clear orders, and reasonable medication doses. People confuse palliative sedation for euthanasia and want to throw stupid amounts of meds at the patient to speed the process, that is not palliative sedation.
Look nursing is sort of like a parent-child relationship in some ways.
Wrong. You are an adult and responsible for your own license and practice. It is your duty to question orders if/when a patient may be harmed. If you don't, you've failed in your duty as a nurse.
If a doctor wrote an order to push potassium, you would do it, and kill the patient, then promptly lose your license. See how flawed that logic is. If you're going to question it then do it anyway why question it? "The doctor wrote an order and I followed it" is NOT acceptable, especially when a patient has died as a result. If you stood in front of a BON and used that as your defense you'd most likely lose your license indefinitely because they would say you lack reasonable judgment to practice safe nursing.
Well this is what I’m talking about. Of course you would not look up a PDR dose and basically come up with the dose for the order. Coming up with the dose IS out of your scope of practice. Do I follow orders ‘blindly’ no. I question orders, I would still complete a WRITTEN order from a physician who was on staff for 2000mg of Fentanyl after I expressed my concern about the dose.
Look nursing is sort of like a parent-child relationship in some ways. Or being a soldier in the military. I may express concern about doses that seem off to me and clarify, but if I’m ordered to do it, and the patient isn’t refusing, then I proceed with the order. Doctors go to school 4-7 years longer than we do for the express purpose of being able to come up with these orders. Orders are not called suggestions for the sole fact that they are meant to be followed.
The problem was not the nurse assisting the MD looking up the dose, the problem was that the MD wanted to give 3X the normal dose (if I understood that poster correctly). I have assisted many Doc's over the years via phone (prior to cell phones etc) to look up dose's, if the dose is correct than no problem taking order and giving.
So you would "complete a written order for the Fentanyl" but would you actually give it.
Let me give you a real example of something that occurred in my hospital. I was working as Charge, nurse came to me after receiving MD order for K-rider bc the dose/rate was not within policy. I called the MD for her to get it changed. MD argues with me that dose is safe (and had documentation to prove), you don't know what you are doing blah blah and hangs up on me. I told the nurse not to give until cleared up. He walks on the unit a few minutes later, does his thing and starts to leave. I take the chart to him (no computer yet) fully open to order page and remind him we need to DC the order and start over again explaining the policy, he continues to complain and argue, states he is going to MN blah blah but does change it. Now, had either of us caved to his nonsense and given the K-rider (knowing full well it was wrong per policy) and something had happened (infiltration/extravasation, cardiac event, who knows) who do you think would be to blame? The doctor would have got his hand slapped and the nurse would have got thrown under the bus. Both were wrong so yeah maybe not fair but it is the job/responsibility of the nurse to make sure the intervention/med is within policy, period! Doctors do go to school longer but they are still only humans who make mistakes. Your choice, your license, do no harm!
Or being a soldier in the military. I may express concern about doses that seem off to me and clarify, but if I’m ordered to do it, and the patient isn’t refusing, then I proceed with the order. Doctors go to school 4-7 years longer than we do for the express purpose of being able to come up with these orders. Orders are not called suggestions for the sole fact that they are meant to be followed.
So if a doctor ordered you to give a paralytic and take a patient off of a ventilator and you questioned the Dr. and he said "yes that is what I want; don't tell me my business" ---- you would just shrug and do it?
Unless I missed it, there is no mention of the facility having a policy forend of life/palliative care. We followed a very strict medication titration protocol. Were families always happy with that...no but it eased the fears and anxieties of those who were coming to terms with their decision. Facilities can't be given a free pass when these things happen but it always seems the onus is on the employee.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
4 hours ago, Luchador said:
So if a doctor ordered you to give a paralytic and take a patient off of a ventilator and you questioned the Dr. and he said "yes that is what I want; don't tell me my business" ---- you would just shrug and do it?
Of course not, but that is one reference in an article that says 40 + people have had their licenses taken away. I’m sorry, but I have done travel nursing and hospital nursing x 10 years. I have worked in many different facilities....I have never worked in one where I was like “yep, every one of these people are uncaring idiots.” Just by the way hospitals are organized 40+ people would represent the staff of at least one possibly 2 floors of a large facility, more of a smaller one. So if EVERYONE here thinks that these people are obviously guilty of not doing their due diligence then I am truly flabbergasted. I have worked with *** doctors, and uncaring stupid nurses, but honestly I find those harder to come by than people that are doing their job as safe and as responsible as possible.
I do not agree with the argument, “They should have known better and said no.” As I have said, I have had to give doses far out of ranges that I am used to. Everyone is making it out like this doctor had to be a pushy *** to get these nurses to do this. What if he gave them an adequate sounding explanation of his doses? People had brought up concerns about the doses and nothing was done for a YEAR! You say something to another nurse and they go, “ Yeah, this has been brought up before, but nothing has happened.”
If I lived my nursing career by y’all’s standards I would never have a nursing position. “Well you may get fired but that is better than being at fault for someone’s death or loosing your license.” Well....maybe. I’m not so sure I would feel at fault for a death following physician orders. Secondly if I can’t work anywhere because I refuse to follow orders I feel are unsafe, then having my nursing license does me little good. In the same manner if all 5 of the facilities in my area don’t want me because I refuse orders, that is almost the same as my nursing license being worthless. Doesn’t really matter if I can get a job “anywhere” when I can’t get one where I live my life.
My nephew is an attorney who has always advised me to make sure if I push a medication I know it is correct. Because I myself can be charged. He sited a case where a doctor orders a medication for a baby or child ( not sure). The Pharmacist filled the medication. The nurse gave it. The child died. The Nurse and her supervisor were charged. Not the doctor or the Pharmacist. The court said the Nurse should have known as other Nurses were testifying against her that the dosage should have been checked and the Physician/Pharmacist notified of the error which resulted in the child's death. So, I am cautious and will question a dosage, not being rude but being concerned. I have been Thanked a few times due to being diligent in a fast pace ER and catching near fatal mistakes.
My nephew is an attorney who has always advised me to make sure if I push a medication I know it is correct. Because I myself can be charged. He sited a case where a doctor orders a medication for a baby or child ( not sure). The Pharmacist filled the medication. The nurse gave it. The child died. The Nurse and her supervisor were charged. Not the doctor or the Pharmacist. The court said the Nurse should have known as other Nurses were testifying against her that the dosage should have been checked and the Physician/Pharmacist notified of the error which resulted in the child's death. So, I am cautious and will question a dosage, not being rude but being concerned. I have been Thanked a few times due to being diligent in a fast pace ER and catching near fatal mistakes.
I am glad you brought this up. I had to laugh when everyone went crazy over the nurse in Tennessee but nurses being criminally charged for a negligent action is far more common than many assume.
I have a family member who has retired from a Board of Nursing and they would either refer nurses to be charged or deal with those nurses who were criminally charged several times a year.
Ignorance or blind obedience to orders is not a legal defense.
At this point you're arguing for the sake of being right. The hospital said he violated their policy. Stop. They fired individuals and thoroughly investigated Dr Death and stuck by their rulings. Stop. You're personal experience is irrelevant to this hospital's policies and what's standard practice in their facility. Stop. Lastly, you're not the only one who has an understanding of hospice/palliative care and familiarity with the meds you listed. Full stop.
So again, what you think is right/wrong is irrelevant because after their thorough investigation and their policy and the fact he circumvented pharmacists means YOU are wrong here. It's not up for discussion. You can't deem a their medical community has "a poor understanding of the practice standards in question" just to make your understanding be correct. My gawd, let it go and get over yourself. ?
I'm not sure at what point I apparently 'kicked your dog', but to your points;
The hospital's investigation has not been made public, so I'm not sure how you've come to the conclusion that they "thoroughly investigated" the incidents in question, what we do know is that they did not have a relevant policy at the time for him and the staff to have violated, and that legal requirements for practice don't vary by facility.
Based on what we do know, there's certainly sufficient reason to take action against Dr. Husel based on his history, but not related to his prescribing practices for patients transitioning from critical care to comfort care since depending on how these were ordered and implemented they were not necessarily outside the dosages required to properly care for these patients. Practice guidelines for transitioning to comfort care from critical care are not based on any "standard" dosages but are instead patient specific, and based on the variables in question the cumulative dosages that may be required by a patient are well within the reported amounts administered, You appear to disagree with this, what do you believe the upper limit of medication requirements to be? What are you basing that on?
Specializes in Surgical Specialty Clinic - Ambulatory Care.
3 hours ago, she244 said:
My nephew is an attorney who has always advised me to make sure if I push a medication I know it is correct. Because I myself can be charged. He sited a case where a doctor orders a medication for a baby or child ( not sure). The Pharmacist filled the medication. The nurse gave it. The child died. The Nurse and her supervisor were charged. Not the doctor or the Pharmacist. The court said the Nurse should have known as other Nurses were testifying against her that the dosage should have been checked and the Physician/Pharmacist notified of the error which resulted in the child's death. So, I am cautious and will question a dosage, not being rude but being concerned. I have been Thanked a few times due to being diligent in a fast pace ER and catching near fatal mistakes.
I have no problems with questioning doses. I just have had doses that I questioned that have been explained to me as why they were ‘okay’ in the MD opinion. And not an *** doctor who I think is reckless. I do document these conversations. But there is just something seriously ***ed up about a nurse being held accountable like that. I will never agree that is something a nurse is responsible for. But if what you say is true then I hope to God I can leave this crazy field, because people have proven over and over again that they are not worth the effort I put in to this....and to get charged for something that is not my responsibility, god, the public isn’t worth this.
Wuzzie
5,238 Posts
And no where did it say that you are to carry out every order without question. We are not robots. To follow your line of thinking why do we even study pharmacology or anything beyond how to do basic nursing tasks? We should just do what the doctor says regardless of how wrong it might be? Is that how you practice?
And FTR it's "perform" not "preform". I wouldn't have pointed this out but it is a repeated error in your posts.