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Drug mix up prompts review at Butler Memorial

A medication mix up at Butler Memorial Hospital, which involved some emergency room patients being given painkillers seven times stronger than the ones doctors prescribed, prompted a review of policy and procedure at the hospital.

Dr. David Rottinghaus, the medical director of the emergency department, said today that the review was broad and involved “about every imaginable department within the hospital.” Rottinghaus said both he and state officials were satisfied with the speed of the hospital’s response once it learned of the mistakes.

A state report on the incidents says the incorrect injections occurred between Aug. 24 and Aug. 31, and involved 18 doses of hydromorphine, known as Dilaudid, that were given to patients instead of doctor-prescribed morphine sulfate.

Hospital officials said no patients were harmed, and that the errors were reported to state officials as soon as hospital officials became aware they had occurred.

The medications are “look alike-sound alike” drugs because of their similar packaging and use, but differ widely in strength. Dilaudid is seven times stronger than morphine, according to a hospital pharmacy technician cited in the state report.

The errors came after pre-filled syringes of the stronger Dilaudid were put into medication dispensers that had already been partially filled with the weaker morphine sulfate. When patients were prescribed morphine sulfate, the report said, staffers used the Dilaudid without verifying the medication name on the syringe.

The administrators said state officials visited the hospital on Oct. 30 and were satisfied with the response to the response plan and they had “no further recommendations for improvement.”

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