Nursing home death prompts investigation
When Herman Felt of Alexandria lost his wife, Darlene, to cardiac arrest last December, something didn't feel right about her death.
He remembered the pain she was in while recovering from congestive heart failure at Bethany Home in Alexandria days before she was rushed to the hospital.
He remembered talking with a doctor who was concerned about the high levels of potassium in her blood.
He requested copies of her medical records and found a big discrepancy. Bethany Home listed her potassium dosage as 80 "millequivalents" a day while hospital records indicated a dosage of 8 millequivalents.
The drug is used to treat patients with chronic heart problems but high doses of it can be fatal.
Felt took his concerns to the Minnesota Department of Health.
Last week, the Health Department released the results of an investigation that confirmed his suspicions: Darlene, 84, died after she was repeatedly given doses of potassium chloride that were 10 times stronger than prescribed.
The Health Department said that medical workers at Bethany Home misread the physician's order for Felt's prescription - believing that an 8 followed by a filled-in circle was "80" when it was actually a scribbled-out mark.
The physician, Dr. Ronald Verant - the Felts' family doctor for more than 25 years - told an investigator that he originally wrote the potassium order for 16 millequivalents to be taken orally, but changed the order to 8 because 8 potassium tablets were easier for a patient to swallow. He said he "crossed out" the 16 and wrote 8.
Verant said he's never given a dosage of 80 millequivalents of potassium in his 26 years of practice.
Bethany Home's policy on administrating medication, which was reviewed and revised in 2006, stated: "When in doubt about dosage or effect of a medication, always refer to the drug references on nursing unit or ask the pharmacist. If any question, withhold medication and consult nurse in charge or attending physician."
In Darlene Felt's case, two nurses and a health information employee, who transcribed Verant's orders, interpreted the dosage as 80.
The pharmacy that received a faxed copy of the order, Thrifty White, called the nursing home to verify the dosage. The pharmacist thought the dosage was unusually high, according to the report, but one of the nurses confirmed the amount.
No one called Verant to clarify the order, according to the report.
One of the nurses later told an investigator that she had no reason to question the order. The other nurse said she questioned, in her own mind, the high dosage, but said that it was a dose she had given before.
'Can't fathom it'
When contacted by the Echo Press, Dr. Verant expressed disbelief over how anyone could have interpreted the scribble as a zero.
"I just can't fathom it," he said. "How it was done, what was done, is beyond me."
Verant added that even if a patient were to need 80 millequivalents of potassium, the order would have said to administer it intravenously - not orally, since it would irritate the digestive tract.
Verant noted that his order called for one 8-millequivalent tablet of potassium to be given twice a day. He said that there is no such thing as an 80-millequivant tablet.
Verant called the incident a "tragic mistake" that led to the death of a "wonderful lady."
The pharmacy has told the media that it was not responsible for the death. Dave Rueter, vice president of personnel for the Maple Grove-based Thrifty White Pharmacy, told the Star Tribune, "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." He declined further comment.
Darlene Felt received 14 doses of 80 millequivalents twice a day over a period of eight days.
She suffered a heart attack on Dec. 1 and was admitted to the Douglas County Hospital with a potassium level of 8.4 - significantly higher than the normal level of 3.5 to 4.1.
She died six days later.
A husband reacts
Felt has found some comfort in knowing that Darlene's death has shed light on the problem of misreading physician's orders for prescriptions. "This is something that should have happened a long time ago," he said.
Felt realizes that no one intended for this to happen to his wife, who he was married to for 62 years. He praised the nurses as being "serious minded" and "great" with their care of Darlene in the past.
But he's still disappointed that he's received only one apology, that one from Carol Kvidt, executive director of Bethany Community.
His wife's death has left him feeling something more than remorse. "It's a different kind of hurt than just having Darlene die," he said.
It also makes Felt angry when he thinks of the six or seven nurses on different shifts who didn't think it was strange to crush up that much potassium and mix it with his wife's applesauce so she could swallow it. "That was a terrible, gross error - to do that so many times for so many days," he said.
Felt credited the Health Department for taking his concerns seriously and promptly investigating.
"I don't want this to happen to someone else - that's the bottom line," he said.
Although she was a quiet person, Darlene was well loved by many in the community, Herman said. She was actively involved in Calvary Lutheran Church, Girl Scouts programs and the Minnesota Law Enforcement Memorial Association. The Felts' son, Curt, was a Douglas County sheriff's deputy who was fatally shot while transferring a prisoner to jail in 1978.
In a statement issued last week, Kvidt said, "Our prayers and deepest sympathies go out to the Felt family. We at Bethany Community are devastated by this event and are working to do everything in our power to ensure such an incident never happens again. The people of Alexandria put the utmost trust in us and our focus is to earn that trust every single day."
The Echo Press contacted Kvidt to find out, specifically, what steps are being taken. Kvidt said the facility is reemphasizing a basic, but effective approach to preventing medication errors: Slowing down, staying focused and following the five rights of medication administration. Those rights include making sure the right patient gets the right drug at the right dose, via the right route, and the right time.
"Such an approach underscores critical thinking and opens the door to asking the right questions about a prescription," Kvidt said.
In her six years as leader at Bethany, Kvidt said she was aware of one other incident that involved a serious medication error. About five years ago a patient received a higher dosage of insulin than prescribed. The patient recovered, she said.
Edenhoff writes for the Alexandria Echo Press. The Bemidji Pioneer and Alexandria Echo Press are owned by a Forum Communications Co. newspaper.