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Report: Medication Errors Led to Patient Death at Boston Children?s Hospital

Accreditation Insider, May 29, 2018

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Boston Children’s Hospital was threatened with termination from Medicare last year after three patients suffered from serious medication errors. An inspection report revealed that one of the patients waited 14 hours for an antibiotic and later died, while two others suffered overdoses of a powerful anesthetic, according to the Boston Globe.

The errors took place between January and November 2017, involving two medications and leading CMS surveyors to threaten Boston Children’s with potential termination from the Medicare program. The patient who died had been prescribed Zosyn, an antibiotic, at noon, but the drug was not administered until 14 hours later, the Globe reported. Two days later, the patient died after developing a sepsis infection.

The other two medication errors involved patients receiving overdoses of Propofol, an anesthetic. The first overdose occurred in January 2017 and was followed by a recommendation from leadership for an improved procedure for measuring Propofol doses. But the recommendations were never developed and 10 months later, another patient was given an overdose of the drug by a doctor using the same procedure. The inspection report said both patients eventually recovered, although the second patient had to be resuscitated.

Boston Children’s was able to avoid disciplinary measures this spring by adding improvement plans to treat sepsis patients immediately and for proper Propofol administration. The inspection report said the hospital failed to properly analyze the errors and correct the conditions that led to them.

The Globe reported that in 2016, Massachusetts hospitals reported 47 medication errors that killed or injured patients.

First published in PSQH. 



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