Oregon brain surgery patient dies after being given wrong drug

A brain tumor patient died unexpectedly in an Oregon hospital's emergency room after she
was accidentally fed the wrong drug through her IV drip, officials said. Loretta Macpherson
died at St. Charles Medical Center in Bend after she was mistakenly given a paralyzing agent
normally used during surgeries instead of an anti-seizure medication, which is routine, reports
KTVZ. "We believe that a tragic medication error occurred," Chief Clinical Officer Dr.
Michel Boileau told KTVZ. And that mistake, that error, has caused her death. This appears
to be a misidentified medicine. We thought we are going to give one medicine, and we gave
another medicine. The 65-year-old suffered cardiac arrest after she stopped breathing. She
died Dec. 3 after life support was switched off. An investigation was launched following the
tragic incident. It emerged that Macpherson, from Sisters, had undergone brain surgery to
remove a tumor at the Swedish Medical Center in Seattle last month. The woman visited St.
Charles Medical Center's ER on Dec. 1 to ask doctors questions about her medication dosage
and how to deal with anxiety. Boileau said she was correctly prescribed fosphenytoin to stem
seizures and that the drug had been successfully delivered to the hospital. But a pharmacy
worker then mistakenly filled the IV bag labeled "fosphenytoin" with a paralyzing drug called
rocuronium, he said. After receiving the medication, a fire alarm went off and a staff
member closed the sliding doors of Macpherson's room to protect her from any potential
hazards. It then took officials 20 minutes to notice the error. "It is a human error," Robert
Gomes, CEO at St. Charles Bend and Redmond, told reporters on Monday. Macpherson's son
Mark said he was devastated about his mother's death, especially seeing as she was expected
to make a full recovery from the brain surgery. "She was the most amazing person on the
planet. There wasn't a person that she didn't get along with. Everyone loved her," he told
KTVZ. Macpherson has not confirmed whether he's planning legal action against the
hospital. Three employees involved in the error were placed on paid leave. The Deschutes
County District Attorney's Office is also conducting a death investigation. Gomes said that
the hospital had now implemented several steps "to ensure that an error of this kind will not
happen again in our facilities." They include the creation of a "safety zone" where

pharmacists and techs are working that is intended to eliminate distractions and the
implementation of a new checking system for paralytic drugs.

Analisis kasus berdasarkan Kode Etik Apoteker Indonesia:

1. Pelanggaran Pasal 9: Seorang Apoteker dalam melakukan praktik kefarmasian harus
mengutamakan kepentingan masyarakat. menghormati hak azasi pasien dan melindungi
makhluk hidup insani.
Implementasi kode etik:
Seorang apoteker harus yakin bahwa obat yang diserahkan kepada pasien adalah obat

yang terjamin mutu, keamanan, dan khasiat dan cara pakai obat yang benar.
Seorang apoteker harus mengambil langkah-langkah untuk menjaga kesehatan pasien
dalam hal ini, apoteker membuat kelalaian yaitu salah memberi obatyang seharusnya
fosphenytoin (obat anti kejang) dengan obat rocuronium (obat kelumpuhan).

2. Pelanggaran Pasal 13 : Seorang Apoteker harus mempergunakan setiap kesempatan

untuk membangun dan meningkatkan hubungan profesi, saling mempercayai,
menghargai dan menghormati sejawat petugas kesehatan lain.
Implementasi penjabaran kode etik:
Apoteker harus mampu menjalin hubungan yang harmonis dengan tenaga profesi
kesehatan lainnya secara seimbang dan bermartabat. Pada kasus ini, terjadi kelalaian
yang mungkin saja tidak adanya pengecekan ulang sebelum obat diberikan.
Seharusnya apoteker dan petugas kesehatan lainnya saling cross cek agar menghindari
kesalahan pemberian obat kepada pasien.
3. Pelanggaran Pasal 15: Seorang Apoteker bersungguh-sungguh menghayati dan
mengamalkan kode etik Apoteker Indonesia dalam menjalankan tugas kefarmasiannya
sehari-hari.
Jika seorang Apoteker baik dengan sengaja maupun tak sengaja melanggar atau tidak
mematuhi kode etik Apoteker Indonesia, maka dia wajib mengakui dan menerima sanksi
dari pemerintah, ikatan/organisasi profesi farmasi yang menanganinya (IAI) dan
mempertanggungjawabkannya kepada Tuhan Yang Maha Esa.
Implementasi penjabaran kode etik:
Apabila apoteker melakukan pelanggaran kode etik apoteker, yang bersangkutan
dikenakan sanksi organisasi. Sanksi dapat berupa pembinaan, peringatan, pencabutan
keanggotaan sementara, dan pencabutan keanggotaan tetap. Kriteria pelanggaran kdoe

etik diatur dalam peraturan organisasi. Dalam kasus ini, petugas yang melakukan
kelalaian telah diskorsing.

Daftar Pustaka
Newsdaily, 2014, Oregon brain surgery patient dies after being given wrong drug,
http://www.nydailynews.com/news/national/brain-surgery-patient-dies-wrongdrug-article-1.2038982
IAI, 2009, Kode Etik Apoteker, Ikatan Apoteker Indonesia, Jakarta