14 Jul Could Mount Carmel deaths have been prevented? – News – The Columbus Dispatch
A Dispatch investigation into Dr. William Husel’s work at Mount Carmel finds that policies on painkiller use were lacking at the hospital system, procedures weren’t followed and recommendations that might have protected patients were ignored.
As 64-year-old Bonnie Austin lay unresponsive on a ventilator in Mount Carmel West hospital’s intensive-care unit, Dr. William Husel ordered a massive dose of fentanyl, one that prosecutors say took her life.
But before the powerful opioid reached its final destination, a nurse implemented an emergency override to access the narcotic from a medication cabinet, a pharmacist verified it and a second nurse pushed it into Austin’s vein.
And in the years before her 2018 death, signs that others had suffered the same fate appear to have gone unnoticed or unreported by nurses, pharmacists, doctors and hospital administrators.
The 43-year-old Husel has been charged with murder in the deaths of Austin and 24 other patients whose final minutes played out in similar ways.
But others played roles, many likely unwittingly, in the excessive doses of painkillers given to many of those patients.
It all happened despite layers of medical protocols that were either overlooked or didn’t exist at Mount Carmel. A Dispatch investigation found that policies were lacking, procedures weren’t followed and recommendations that might have protected patients such as Austin were ignored.
Attorney Gerald Leeseberg, whose firm is handling several wrongful-death lawsuits involving Mount Carmel and Husel, said there were many opportunities along the way to find out what was happening and do something about it.
“Was Husel off the rails? Absolutely,” Leeseberg said. “The problem is that the Mount Carmel system and the people failed to detect immediately that he was off the rails. All those holes lining up is what caused this.”
>> Read more: A timeline on the William Husel case
Husel, of Liberty Township near Dublin, was fired by Mount Carmel in December, his medical license has been suspended and he has pleaded not guilty to the criminal charges.
Franklin County Prosecutor Ron O’Brien has said the doctor, over about four years, ordered doses of fentanyl that hastened or caused the deaths of 24 patients at the now-closed Mount Carmel West hospital in Franklinton and one patient at Mount Carmel St. Ann’s in Westerville. Husel’s lawyer has said the doctor was providing comfort care to end-of-life patients and did not intend to kill anyone.
Until last week, he was one of the only employees who lost jobs over the deaths. But on Thursday, Mount Carmel President and CEO Ed Lamb announced that he will resign, that the health system’s top clinical officer will retire and that 23 employees, including five managers, were fired. Several nurses also face possible sanctions on their licenses.
More than 100 pages of medical records provided by Austin’s husband detail her Sept. 30 trip from a recliner in front of the TV in their West Side home to the ICU where her life ended.
She arrived at Mount Carmel West at 7:37 p.m., Columbus Fire Division records show. She died seven minutes before midnight, with at least three medical personnel — two physicians and a nurse — at her bedside, according to a note in her chart.
Mount Carmel, in announcing its internal investigation in January, took responsibility for not having processes in place to prevent ICU painkiller overdoses. It has implemented several new policies to correct medication administration issues, as evidenced in correction plans provided to the U.S. Centers for Medicare & Medicaid Services.
The health system has said its investigation identified a total of 35 seriously ill patients who had received excessive painkiller doses, with 29 of those doses potentially fatal. Five of the patients, it says, might have improved with proper care.
But Mount Carmel officials have not revealed what their policies were at the time of the patient deaths and, in response to questions about several procedures, told The Dispatch that many already have been answered.
“Our team at Mount Carmel Health System is dedicated to providing safe, high-quality and compassionate care to all our patients — just as it has for over 130 years,” the system said in a prepared statement.
“As previously shared, we have taken steps to ensure that events like these never happen again; however, in light of ongoing legal proceedings, Mount Carmel will not comment further on the specific facts or circumstances surrounding the care provided by Dr. Husel.”
O’Brien said he learned through his investigation that Mount Carmel did not have a system in place to audit or track the amount of medications, including fentanyl, that was being dispersed in the ICU prior to October, when the health system received its first formal complaint about Husel.
He also said there were instances in which either a nurse or pharmacist had raised questions about painkiller dosages ordered by Husel. But those questions or complaints didn’t make it up to the administrative level.
Attorney David Shroyer, who represents Bonnie Austin’s husband, David, in a wrongful death lawsuit, said the tragedy “has Mount Carmel’s fingerprints all over it.”
“It’s a disaster. … You don’t have systems in place to protect against mistakes, much less murder,” Shroyer said.
At 11:10 p.m. Sept. 30, Husel ordered 600 micrograms of the opioid fentanyl to be pushed into Austin’s IV line over three to five minutes along with 6 milligrams of the sedative midazolam (Versed), records show. Mount Carmel policy that was updated after Husel was fired sets the usual adult dosages at 25 to 100 micrograms for fentanyl and 0.5 to 4 milligrams for midazolam, according to an Ohio Department of Health inspection report.
A pharmacist approved the dosages for Austin at 11:15 p.m.
Information in documents from the State of Ohio Board of Nursing and the health department shows that a nurse had used an override that avoided warnings and withdrew the medications from an electronic drug-dispensing cabinet at 11:12 p.m.
They were provided to a second nurse, who administered the drugs at 11:23 p.m. Austin was pronounced dead 30 minutes later.
>> Read more: Here are the victims in the Mount Carmel criminal case
David Austin said he wants Husel and the hospital held responsible in the death of his wife of 37 years.
“They should have known long beforehand,” he said of administrators. “When he had ordered … that many prescriptions, they should have been warned, that’s a no-no.”
Among those suspended after the Husel investigation began were pharmacists who approve drugs and nurses who administer them. But there were others involved in the patients’ care who might have had an opportunity to review medication records.
They include attending physicians, who would have admitted patients and perhaps signed death certificates, and primary care physicians who would have been notified of the deaths. Austin’s files indicate that a “clinical documentation specialist” had accessed her record, making an undated note to ask for clarification on her diagnosis and the severity of her condition.
The Franklin County coroner’s office ruled on the cause of death for two patients, one who died before Austin and one who died after her. Both deaths were ruled accidental and both patients had fentanyl in their system. Reports indicated that one had used cocaine and the other had used carfentanil, morphine and ethanol.
Franklin County Coroner Dr. Anahi Ortiz declined to comment on the investigations. The Dispatch also has reached out to several pharmacists and nurses, as well as other doctors who treated Husel’s patients and signed death certificates. They either declined to comment or couldn’t be reached.
Without access to Mount Carmel’s past policies, it is unclear whether the health system required supervisors to review charts after patient deaths in the ICU, or whether there were any other quality-control reviews or processes. And it is unclear what rules were in place for questioning the orders of a physician or how complaints were to advance along a chain of command.
It’s also unclear whether there was a process in place for investigating the drugs being taken from the machines by override, though the health department report indicates that “the hospital failed to ensure a system was in place to monitor and prevent” large doses of drugs such as fentanyl, Versed and hydromorphone (Dilaudid) from being accessed from the machines via override.
Dozens of Mount Carmel patients died under circumstances similar to Austin, receiving dosages of fentanyl as high as 2,000 micrograms and midazolam as high as 10 milligrams, often as they were taken off ventilators. A handful of patients also were given Dilaudid at dosages as high as 10 milligrams, with current Mount Carmel policy setting the usual dose at 0.5 to 4 milligrams, according to health department records.
In nearly all cases, medications were obtained from electronic drug-dispensing cabinets via overrides, which current Mount Carmel policy says should be used only in emergency situations to sustain life. At times the orders were verified by pharmacists beforehand, other times they were verified after administration, and sometimes the overrides bypassed the pharmacy altogether.
Leeseberg specifically pointed to a lack of oversight for the overrides used to access excessive amounts of fentanyl for patients being removed from ventilators as a protocol failure.
“You needed to verify this was a legitimate emergency,” he said. “Had they done that the first time Husel had ordered 200 or 400 or 500 or 1,000 micrograms, they would have determined the order wasn’t for a legitimate emergency override. And then they would have suspended him or fired him and maybe you have one dead patient.”
Mount Carmel’s hospitals are accredited by the independent, nonprofit Joint Commission, which requires policy on prescribing pain medication, and last year instituted a requirement for policy describing what medication-cabinet overrides will be reviewed and the frequency of such reviews.
Among all U.S. hospital errors, medication errors are the most common, said Erica Mobley, director of operations for Leapfrog Group, an agency that reviews hospitals twice a year on various measures, including errors and staff.
Mount Carmel West received B grades on its two latest rankings, and had received Cs on its five previous rankings.
In the most recent report, the hospital received sub-par scores regarding practices for doctors ordering medications through a computer, safe medication administration, communication about medicines and issues with leadership effectiveness in preventing errors.
At the Institute for Safe Medication Practices in Pennsylvania, recommendations on the cabinets were recently updated. The changes were prompted by the January announcement of the Husel investigation as well as a reckless homicide charge that was filed in February against a Tennessee nurse who used an override to inadvertently withdraw the powerful paralytic vecuronium instead of Versed for a patient.
Michael R. Cohen, founder and president of the watchdog institute, said hospitals should limit the quantity and size of medication dosages stored in the cabinets.
“Another major thing, and not everybody does this, but we recommend that somebody needs to be reviewing the overrides and what was taken from the cabinet on a daily basis to see if anything looks unusual,” he said.
Mount Carmel has updated its policy to limit the amount of fentanyl available by override in the ICU to 250 micrograms and, overall, reduced the number of medications available for override by 55%. It also has policies for monitoring override orders for drugs like fentanyl, Versed and Dilaudid.
Cohen said hospital culture also can come into play.
“You can almost get talked into it, depending on the individual’s personality, and their level of knowledge or the perception of their level of knowledge,” Cohen said. “… These things happen behind the scenes, and once it gets by the first time it can become normalized.”
O’Brien is aware that some family members and members of the public believe others at the hospital should have been criminally charged. But he stands by the decision to indict only Husel and not nurses and pharmacists, some of whom will serve as witnesses for the prosecution.
“There are different levels of culpability, not everything that is wrong is a crime,” O’Brien said. “There are many things that are wrong that we questioned, but it doesn’t mean they can be prosecuted in court.”
Austin was very ill. She’d suffered a cardiac arrest and a collapsed lung, her kidneys were failing and she’d been hospitalized earlier that month for breathing problems and coughing up blood.
Still, her husband believes that without that dose of fentanyl, she might have walked out of the hospital, just like she had after those previous visits.
But he will never know for sure.
Austin said Husel had told him his wife was “brain dead, heart dead and lung dead” and asked if he wanted to withdraw life support. Knowing that his wife had not wanted to live on a machine if there was no hope, he said yes. But he did not know that she would be given a potentially fatal dose of fentanyl before her breathing tube was removed.
“Maybe I should have waited. Maybe I should have said no,” he said in Shroyer’s office, tearing up and hitting himself on the thigh. “… I still blame myself. I blame him, yes, and the hospital, yes, but I blame myself. I trusted him.”
Shroyer said the attention being afforded the deaths will likely save lives across the country.
“We’re hoping that every hospital has a board discussion where the simple question is asked, ‘Did you hear what happened in Columbus, Ohio? Could it happen in our hospital?'”