An unfolding tragedy in Ohio is once again highlighting the need for hospitals to pay close attention to the control and use of narcotics. An intensive care doctor ordered “significantly excessive and potentially fatal” doses of pain medicine for at least 34 near-death patients. 28 patients subsequently died after receiving what one attorney, who filed suit described as “grossly excessive dosages of fentanyl.”
Ohio does not have laws in place for physician-assisted death. Regardless, even given the condition of the patients, no communication appears to have taken place in this regard. Joe Carrese, a faculty member at the Johns Hopkins Berman Institute of Bioethics commenting publicly on the case, said that laws surrounding this issue are carefully constructed. In this situation, he noted that if the physician in question administered lethal quantities of drugs to unwitting patients in order to end their lives, his acts did not meet the definition of physician-assisted death. “In this case, if that was the intent, this was essentially euthanasia, which is not legal anywhere in the United States and not at all the same as physician-assisted death.”
This situation came to light because an employee reported a safety concern. However, it appears that until that time the checks and balances that should have been in place to address these types of doses were either not in place, not followed, or insufficient. The hospital’s CEO stated, “We take responsibility for the fact that the processes in place were not sufficient to prevent these actions from happening.” The physician in question was fired and the hospital removed 20 employees from patient care pending further investigation, including nurses and pharmacists. The attorney filing the initial suit noted that multiple people were involved in the patients receiving the drugs. “The pharmacist has an obligation to question an order, and the nurse has an obligation to question the order as well.” “All of those safeguards were overridden or ignored. It’s like nothing I’ve ever seen.”
A culture of trust is one of the primary enablers for controlled substance diversion or misuse. This was a trusted physician. However, in any case where things don’t seem right, all health care professionals are obligated to speak up and question. An established culture of safety is essential so that employees feel safe to express their concerns.
Finally, this situation highlights the need to regularly review and assess the effectiveness of internal safeguards. Do nurses and pharmacists fully understand the use of pain medications and dosages? Do pharmacists have timely and full visibility to the necessary patient information, orders and doses being administered? Are maximum dosage limits set as hard stops in the computer system without the ability to override the limits? Are irregular doses flagged and followed up to detect inappropriate prescribing patterns? Are periodic external reviews of the hospital’s controlled substance processes conducted to help identify gaps or problems?
Sadly, in health care, we often fail to learn from the misfortunes of others. “Well that is indeed a tragedy but that could never happen here,” is an all too frequent response. However, this type of occurrence can happen anywhere, and all hospitals should have systems in place to prevent misuse or diversion, and these systems should not be “static.” This is an ever-evolving challenge and hospitals should regularly evaluate their practices, safeguards and control of these drugs.