Becker's Hospital Review

73 FINANCE CMO / CARE DELIVERY Inspection report faults Boston Children's for medication errors linked to patient death By Megan Knowles I n 2017, three patients suffered from med- ication errors at Boston Children's Hospi- tal, including one patient who waited 14 hours for an antibiotic and later died, accord- ing to a state and federal inspection report cited by e Boston Globe. Here are eight things to know: 1. e errors took place between January and November 2017 and involved two drugs. e mistakes prompted federal regulators to threaten Boston Children's with termination from the Medicare program. 2. For the patient who died, caregivers ordered an antibiotic, Zosyn, at noon on a day the pa- tient was receiving treatment in the hospital's intensive care unit. However, the inspection report revealed a nurse did not give the pa- tient the antibiotic until about 2 a.m. the next morning. e patient developed sepsis and died two days later. Aer the antibiotic was prescribed, the patient's nurse mistakenly thought someone had given a verbal order to hold the medicine for further test results. Aer the patient's death, hospital leaders sent an alert to physicians and nurses in the intensive care unit to remind them all med- ication orders should be in writing to avoid confusion — except in an emergency. Inspec- tors said the hospital failed to alert caregivers across the hospital about the rule. 3. Two other Boston Children's patients re- ceived overdoses of the anesthetic Propofol. Aer the first overdose in January 2017, hos- pital leaders suggested implementing a clear- er procedure for measuring doses. Inspectors interviewed one of the hospital's pharmacists, who claimed those recommen- dations "never materialized," according the report. Ten months later, a physician ad- ministered an overdose to a different patient using the same potentially confusing proce- dure. at second patient stopped breathing and was resuscitated, but hospital executives said both overdose patients recovered. 4. Aer these incidents, this spring, the hos- pital implemented improvements for treating sepsis patients quickly and for administering Propofol accurately, avoiding CMS discipline. 5. Jonathan Finkelstein, MD, chief patient safety and quality officer for Boston Chil- dren's, did not discuss specific cases, but told e Boston Globe when there is a mis- step "we set out the very next day to im- prove care." 6. In the 46-page report, inspectors said the hospital did not completely analyze the er- rors and thoroughly correct the conditions that led to the errors. Inspectors based report findings on visits to the hospital over five days in November and December 2017. 7. Dr. Finkelstein said the hospital put a new protocol in place that triggers a sep- sis evaluation for any patient with a dete- riorating condition. Additionally, Boston Children's sent out a hospitalwide alert that states when medications are handed off to another clinician, only a single, la- beled, weight-based dose can be prepared in a single syringe. 8. In a 63-page improvement plan, Boston Children's recognized "the need to focus ad- ditional attention in our responses to specific events," including "the potential of a similar event occurring in another area." n FDA greenlights first nonopioid drug for opioid withdrawal By Megan Knowles T he FDA approved Lucemyra, the first nonopioid treatment for adults managing opioid withdrawal symptoms, the agency announced May 16. Lucemyra is an oral medication that reduces the release of norepinephrine, which is believed to be associated with opioid withdrawal symptoms. Although Lucemyra may lessen the severity of withdrawal symptoms, it may not en- tirely prevent them and is only approved for treatment for up to two weeks, the agency stated. The drug is not for treating opioid use disorder but can be used as part of a long-term plan for managing it, the agency added. "We're developing new guidance to help accelerate the development of better treatments, including those that help manage opioid withdrawal symptoms," said FDA Commissioner Scott Gottlieb, MD. "We know that the physical symptoms of opioid withdrawal can be one of the biggest barriers for patients seeking help and ultimately overcoming addiction." Patients' fear of experiencing withdrawal often hinders them from seeking treatment, and those who do seek help may relapse due to ongoing symptoms, Dr. Gottlieb added. "The FDA will continue to encourage the innovation and development of therapies to help those suffering from opioid addiction transition to lives of sobriety, as well as address the unfortunate stigma that's sometimes associ- ated with the use of medication-assisted treatments," Dr. Gottlieb said. n

• Cover