Misread Rx led to nursing home patient's death

  • Article by: PAUL WALSH and BRAD SCHRADE , Star Tribune Staff Writers
  • Updated: November 14, 2011 - 11:29 AM

Mistake shows how hard-to-read prescriptions often lead to tragic results.

A Minnesota nursing home resident died after she was repeatedly given doses of potassium chloride that were 10 times stronger than prescribed because medical workers misread the prescription, a state investigation has found.

State regulators blamed the deadly error on Bethany Home in Alexandria, saying Darlene Felt's death "indicates a widespread systemic problem." Potassium chloride can be used to treat patients with chronic heart problems, but high doses are used in combination with other drugs to execute prisoners.

Felt, 84, died of cardiac arrest last December after receiving 14 doses of the drug, which came in pills so large that Felt couldn't swallow them, according to Jim Sherburne, a St. Louis Park-based attorney representing Felt's husband, Herman. Sherburne said the compound had to be crushed and given to Felt in applesauce twice a day.

Carol Kvidt, executive director of Bethany Home, said in a statement: "We're working to ensure this never happens again."

The mistake raises questions about a problem that has plagued the medical profession for years -- poor penmanship and difficult-to-read prescriptions. Medication errors lead to an estimated 7,000 deaths a year, according to a 2006 report from the National Academies of Science's Institute of Medicine.

Felt's problems started with a doctor's handwritten order that was misinterpreted by three employees at Bethany Home, according to a report from the Minnesota Health Department made public this week.

Felt was supposed to be taking 8 millequivalents of potassium chloride twice a day, but the doctor's order showed an 8 next to a filled-in circle, which the state report characterized as a "scribble." A transcription secretary and two licensed nurses at Bethany Home interpreted the dark circle as a 0 - or 80 units.

The pharmacist called Bethany to verify the information because it was such an "unusually high dose."

A Bethany nurse assured him it was accurate, so he filled it, according to the report. One employee later told investigators that she didn't question the dosage because she had given that much potassium chloride to other residents before.

"It was a terrible situation," Sherburne said. "Someone should have checked with the doctor if there was some question before they gave her 14 or 15 of these doses."

Felt's husband serves on the Bethany board and has been its chairman.

"They acknowledged they made a mistake," Felt said Thursday. "I know these nurses really well. They are absolutely sick [about his wife's death]. They treated her like a queen."

The prescription was filled by a Thrifty White Pharmacy in Alexandria. An executive with the Maple Grove-based company said the pharmacy was not responsible for the death.

"Obviously, the death of any patient is always a concern for us whether it's got anything to do with our prescriptions or just the normal course of life," said Dave Rueter, vice president of personnel for Thrifty Drug Stores Inc. He declined to make any further comment.

Herman Felt said the doctor who prescribed the drug was Dr. Ronald Verant, his family physician for more than 25 years.

Verant said he was shocked when he learned about the dispensed dosage. He said he's never given that kind of dose.

"I don't feel I made a med error. I couldn't believe that dose was given to a patient," Verant said.

Pharmacist Mark Trumm of Trumm Drug in Alexandria has filled many of Verant's prescriptions and said his handwriting isn't remarkable compared with others'. But he said that poor handwriting is common among doctors.

"I've questioned a lot of doctors' handwriting," Trumm said. "I wouldn't say his stands out as far worse than anybody else."

In recent years, Verant and other doctors have begun sending many prescriptions electronically, but nursing homes don't often have the same technology, Trumm said. Advocates have said thousands of lives could be saved each year if all medical providers were required to use electronic prescription systems.

In response to the incident, Bethany Home took several corrective actions, including a review of its policies and procedures, and counseling and re-education for all staff members involved in the case.

Darlene and Herman Felt were married for 62 years and raised four children.

One of them, Douglas County sheriff's deputy Curt Felt, was fatally shot in 1978 by a prisoner who was being transferred from court to jail. His death inspired Darlene Felt to become active in the Minnesota Law Enforcement Memorial Association.

Star Tribune database editor Glenn Howatt contributed to this report. Paul Walsh • 612-673-4482 Brad Schrade • 612-673-4777

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    State regulators say Darlene Felt died because this prescription was misinterpreted as 80 instead of 8 millequivalents of potassium chloride.

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