After a lengthy investigation by the Kentucky Board of Pharmacy, the board decided in December to give two years probation to a pharmacist involved in a medical mix-up that resulted in a patient’s death in 2022.
The investigative summary in the case, which LEX 18 obtained through an open records request, stated that the pharmacist “failed to follow policy and procedure” when he sent a medication label to a nurse without visually verifying that she had the correct medication.
The patient in question was sent to CHI Saint Joseph Health Main in Lexington in June of 2022 because of a gastrointestinal bleed, according to documents released last summer in the Kentucky Board of Nursing’s investigation into the incident.
The patient was set to be given a colonoscopy and was supposed to be given a bowel prep medication called GoLytely ahead of it, according to the documents.
Instead, the patient was given a dialysis liquid called NaturaLyte, according to the investigative reports by the boards of pharmacy and nursing. The patient died hours later.
According to an investigation by the Kentucky Board of Nursing, a series of errors led up to the patient’s death. The dialysis solution was mistakenly left on the floor where the patient was being cared for by a dialysis team. The nurse then mistook the dialysis solution for the colonoscopy prep because the jugs look similar.
When the nurse tried to scan the medication to make sure it was correct, it would not scan. The nurse then called the pharmacy, but rather than double-checking the medication or sending up a new jug, the pharmacist sent up a new label for the nurse to scan.
The investigative summary listed multiple factors that contributed to the fatal error, including the nursing staff levels that day, a nurse’s failure to double-check the medication information, the failure of a third-party contractor to remove the dialysis solution from the floor and the pharmacist’s failure to visually verify the medication before sending up the label to the nurse.
The pharmacy board investigation also noted that the pharmacist was terminated by the hospital in March after three separate, unrelated medication errors in the span of about a week in February of 2023. Those medication errors were caught by other employees before they reached the patient, according to the summary.
In addition to getting two years of probation, the pharmacist was ordered to pay a $1,000 fine and complete 12 hours of continuing education on medical errors, according to the pharmacy board order. He is also prohibited from accepting a position as a pharmacist in charge while on probation.
