Patient Died Due to Misread Prescription

Felt died in December 2010 after she repeatedly received the wrong dose of potassium chloride. While the drug can be used to treat chronic heart problems, potassium chloride is also used in high doses as part of the cocktail used in prisoner executions. Mrs. Felt was given medication 10 times stronger than what her doctor prescribed on 14 occasions, leading to cardiac arrest. According to her family’s medication error attorney, Jim Sherburne, the pills were so large they had to be crushed into Mrs. Felt’s applesauce twice a day.

The Star Tribune reported the drug error began with a doctor’s difficult to read handwritten order. Classified in the investigative report as a “scribble” the prescription was for 8 milliequivalents of potassium chloride. The 8 was followed by a filled in circle, leading the order to be misread as 80 milliequivalents by three different nursing home personnel. The pharmacist filling the order called to question the high amount, but the nursing home never contacted Felt’s doctor to verify.

Minnesota investigators have attributed Felt’s death to the actions of the nursing home. The doctor and pharmacy have both denied any responsibility for the medication error. The nursing home has reevaluated its policies and practices and worked to reeducated its employees.


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