health system type not for profit healthcare not for profit hospitals industry healthcare headquarters bend oregon website stcharleshealthcare.org st. charles health system inc. schs is a four hospital network and healthcare company in central oregon . headquartered in bend the system owns and operates the st. charles medical centers in bend redmond madras and prineville . schs is a private not for profit oregon corporation and with more than 3 000 employees it is the largest employer in the region . 1 contents 1 history 2 notable events 2.1 loretta macpherson death 3 see also 4 references 5 external links history edit then mountain view hospital in madras entered into an agreement with schs to provide management services for the hospital in 1998 . 2 in 2001 redmond s central oregon district hospital became a part of the system with st. charles then taking over the operations of prineville s hospital in 2008 . 2 mountain view hospital then merged into the system in 2013 and became st. charles madras . 2 notable events edit loretta macpherson death edit on december 1 2014 a local resident loretta macpherson was admitted to the st. charles medical center s emergency department to be seen for anxiety which she had been suffering several days after a successful brain tumor removal at the swedish medical center in seattle washington . when macpherson informed doctors at the st. charles medical center er department of her anxiety issues the physician ordered an anti seizure medicine . the attending physician put the order into the st. charles pharmacy department and the order was received correctly however the pharmacy inadvertently prescribed macpherson the wrong medication . instead of fosphenytoin the pharmacy department mislabeled an iv bag of rocuronium a paralyzing agent . the mislabeled drug was administered to macpherson causing her to stop breathing and to go into cardiopulmonary arrest . she experienced an anoxic brain injury and was put on life support . she was taken off of life support and died three days later . 3 4 the st. charles health system later put out a series of press releases admitting fault with the clinical chief officer dr. michael boileau stating ; we believe that a tragic medication error occurred and that mistake that error has caused her death . this appears to be a misidentified medicine . we thought we are going to give one medicine and we gave another medicine . 5 6 the medication error resulting in macpherson s death sparked extensive media coverage . 7 8 9 10 11 12 on september 22 2015 it was discovered that a federal report by the u.s. centers for medicare & medicaid services completed an investigation into the december 1 2014 event revealing that the medication mislabeling was not the only major error that allegedly led to macpherson s death . the federal report states that the hospital received three violations including patient rights pharmaceutical services and nursing services . 13 among allegations the federal report states that the st. charles emergency room physician overseeing macpherson had ordered the attending nurse to provide continuous cardiac monitoring and continuous pulse oximetry monitoring for the patient prior to medication being administered . dr. michel boileau st. charles chief clinical officer was quoted in december saying that the staff determined that monitoring macpherson s vitals was not necessary . there wasn t any indication to do so her management and the degree of surveillance and observation that she was given was appropriate for the medicine that the staff believed she was receiving . 14 the federal cms report includes information about the hospitals policy s to monitor response to any medication and particularly one that is being given for the first time is monitored by nursing staff for therapeutic or adverse effects . this monitoring includes but is not limited to vital signs lab values blood levels therapeutic ranges and the patient s perceptions . documentation of patient s response to all prn medications is required . 15 the federal report also includes instructions from www.drugs.com to monitor patients closely 16 when receiving fosphenytoin via iv along with the 2013 nursing handbook . the report concludes that the nurse handling macpherson acknowledged the doctors order to hook up pulse oximetry monitoring but then discontinued it without an order to do so . the report further acknowledges that the nurse never hooked macpherson up to cardiac monitoring . 17 the report ends with acknowledging that macpherson s room was located directly across from the nurses station and the chief nursing officer states if the patient had been on cardiac monitoring as ordered an audible alarm would have sounded and alerted staff at the nurse s station when the patient s cardiac status declined . the incident is under investigation by deschutes county district attorney john hummel . 18 see also edit st. charles medical center bend st. charles medical center heliport list of hospitals in oregon references edit madras hospital seeks acquisition by st. charles . ktvz.com . july 25 2012 . retrieved january 1 2014 . a b c hagemeier heidi january 10 2013 . madras hospital is now st. charles . the bulletin . retrieved january 1 2014 . ktvz news december 3 2014 . tragic error st. charles probing wrong drug death . the bend bulletin december 4 2014 . error at st. charles bend results in patient s death . the bend bulletin december 5 2014 . st. charles bend admits mistake led to patient death . ktvz news december 8 2014 . wrong drug put in iv bag led to fatal bend hospital error . united kingdom daily mail news december 9 2014 . patient 65 died at oregon hospital after nurse filled iv bag with the wrong drug . canadian business news december 4 2014 . oregon hospital says patient died after getting paralyzing agent instead of anti seizure drug . iraq news face iraq december 9 2014 . oregon brain surgery patient dies after being given wrong drug . australia news one page news december 5 2014 . st. charles probes death . fox news . pharmacy error led to patient death hospital confirms . cbs news . hospital medication error kills patient in oregon . u.s. centers for medicare & medicaid services federal report st. charles january 26th 2015 . the bend bulletin . federal report st. charles patient not monitored before death . violation nursing services section 3 . u.s. centers for medicare & medicaid services federal report st. charles january 26th 2015 . fosphenytoin dosage form iv . violation nursing services section 5 . . ktvz news september 22 2015 . st. charles patient death spurs federal investigation citation . external links edit u.s. centers for medicare and medicaid services federal report january 26th 2015 retrieved from https en.wikipedia.org w index.php title st. charles health system & oldid 740270226 categories bend oregonhospital networks in the united statesorganizations based in oregonhidden categories 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