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Brain Injured Patient Who Could Not Swallow Still Given Prevacid by Mouth for 53 Days at MAHC

Our mother’s injuries left her unable to swallow.  Her condition was designated as “NPO,” the medical term indicating that she was to receive nothing by mouth.  All of her medication and nutrition had to be delivered through an enteral feeding tube that had been inserted into her stomach.  There was a serious risk of choking and aspiration, both of which can be life-threatening, if any medication was given by mouth.  Yet that is exactly what happened at MAHC on 53 occasions with Prevacid alone.  It was not until the family discovered the error and brought it to the attention of the care team that the drug was finally administered correctly.   

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Prevacid medication administration entry prepared by nursing staff.

On a return visit one evening, we found our mother, who had been left alone, choking on a large tablet in her mouth which soon caused her to vomit.  We learned that the drug Prevacid had been given to her ‘PO’ (by mouth), contrary to specific medical orders — not to mention common sense.

Prevacid was necessary to prevent acid reflux, which can substantially increase the risk of aspiration, and possibly pneumonia.  But because of the dangerous way nursing staff had been administering the drug, the resulting choking and vomiting was elevating to an even higher level the likelihood of the very aspiration the drug was supposed to be preventing. The same distinct orange-coloured stain produced by the emesis on this occasion had been found frequently on our mother’s clothes in preceding weeks, although we never knew the reason, and nursing staff always claimed to be unaware of the cause when we inquired.

When we discovered what was happening on this occasion, we immediately raised the issue with the attending nurse and were told that they had been administering Prevacid by mouth ever since our mother’s admission to the hospital.  In fact, the chart reveals that on some 53 occasions, nursing staff at MAHC had either given, or attempted to give, the drug by the wrong route, each time exposing our mother to life-threatening risks of choking and aspiration.

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Doctor’s medication order for Prevacid.

But even our intervention was not enough to set the situation right.  Shockingly, the doctor who ordered a different formulation of the drug so that it could be delivered correctly substituted one wrong-route error with another.   His prescription directed: “open capsule Prevacid 30, in tube feed.”  Putting medication in the “tube feed” is exactly not how to deliver it properly.  According to evidence-based guidelines, drug safety alerts, and protocols that have been adopted by most hospitals, medication should never be added to enteral feeds, as that can lead to a number of adverse interactions.

After obtaining our mother’s chart following her discharge and looking into the situation further, we also found dozens of errors by the hospital pharmacy, which had persistently directed that Prevacid be given by mouth.  None of these errors was ever corrected by nursing staff, who themselves repeatedly entered incorrect directions on the medication administration record, causing the drug to be given to our mother by the wrong route day after day.  How this could happen when it was obvious that our mother could not swallow anything safely has never been explained.  In fact, the hospital continues to deny that these –or any of the thousands of other medication errors we identified– ever happened.  All of the wrong route errors we discovered were evident in the record the hospital created, and still the CEO, chief of medicine and chief nursing officer at MAHC have refused to acknowledge any medication errors.  MAHC produced a report that claimed medication was administered appropriately. Its CEO insists that our mother “received appropriate care while she was a patient at Muskoka Algonquin Healthcare.”  The hospital nevertheless refuses to address the above errors, based on the chart, involving Prevacid.  It has declared the matter closed.  No apology has ever been forthcoming for the adverse reaction our mother frequently had to this drug and the needless risk to which she was being exposed each day.

Even after our intervention and a change was supposed to be made in the drug’s delivery route, errors continued.  So oblivious was the hospital’s pharmacy to the true state of our mother’s condition that when it finally awoke to the fact that it had been dispensing Prevacid with wrong-route instructions, it then incorrectly directed nurses to administer the drug via NG (nasogastric) tube.  Our mother never had an NG tube for her entire stay at MAHC.  The hospital refuses to acknowledge this error as well.

When reviewing our mother’s hospital chart, we were shocked to find that Prevacid was not the only drug given to her by mouth.  Her medical records confirm that dozens of doses of other medications were also delivered orally, leading us to fear that the episode of aspiration pneumonia she developed – which the hospital claimed was so serious she could die – may have been caused by one of the many instances where she was given medication incorrectly by mouth.  

What is truly shocking is that wrong-route medication errors were only a small part of the complete breakdown in care and safety our mother faced while she was a patient at MAHC.  

This is hardly the “appropriate care” its CEO claims.