Mount Carmel: 5 patients affected by excessive doses may have survived with proper care

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COLUMBUS – Mount Carmel Health System announced Friday that it has identified five patients who died after receiving excessive doses of pain medication whose conditions may have been able to be improved with treatment.

That news came as the hospital identified an additional patient who have received an excessive dose of pain medication – now bringing the total number of patients affected to 35.

“As previously shared in our last announcement, we've also been investigating whether any of the affected patients received excessive doses of pain medication when there was still an opportunity for treatment to improve their immediate condition. We are aware of five cases in which this possibility was a concern and we are reaching out to the loved ones of these patients to share this information. Our hearts go out to these family members. They continue to be in our thoughts and prayers,” Mount Carmel President and CEO Ed Lamb said in a video statement.

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“I know that confidence has been shaken. Please know we are doing everything within our power to rebuild that trust.”

The hospital did not identify who those patients were but said: “We also have been investigating whether any of the affected patients received excessive doses of pain medication when there was still an opportunity for treatment to improve their immediate condition. We are aware of five cases in which this possibility is a concern, and we are reaching out to the loved ones of these patients to share this information.”

The hospital’s statement went on to say:

These events are heartbreaking, unacceptable and inconsistent with the values and care processes of Mount Carmel. As we work to understand how this happened, we continue to implement meaningful changes to ensure they never happen again. So far, we have:

  • Added a new protocol to set maximum appropriate doses for pain medication in our electronic medical record system;
  • Implemented a new escalation policy for deviations in our pain medication protocols;
  • Restricted the ability to bypass pharmacy review of medication orders;
  • Increased clinician education on standards and practices regarding end-of-life care;
  • Implemented numerous other initiatives to ensure patient medication safety;
  • Initiated a review of our culture of safety initiative to identify what needs to change; and
  • Engaged independent experts who are assisting us with this process.


All told – 35 patients are believed to have received excessive doses of pain medication between 2014 and 2018. The hospital fired ICU intensivist Dr. William Husel, who treated these patients, and placed 23 employees – including 14 nurses, 6 pharmacists and three additional employees that included members of management on leave. One pharmacy manager, Janet Whittey, is no longer with Mount Carmel. The hospital has declined to say if she was fired or quit.

This announcement by Mount Carmel comes one day after the Centers for Medicare and Medicaid Services announced that it would not be terminating Mount Carmel West from participating in the Medicare program – as was originally indicated in a January letter to Mount Carmel. Prior to Friday’s announcements, it was known that thirty-three patients who died attended Mount Carmel West; one attended Mount Carmel St. Ann’s in Westerville. It was not clear Friday morning where the 35th patient attended. Twenty-nine of the patients received potentially fatal doses, the hospital has said.

Last week, CMS released documents on Mount Carmel West and Mount Carmel St. Ann’s. State health inspectors working on behalf of CMS found that the hospital failed to establish a system to monitor or prevent large doses of medications from being accessed via an override. In 24 of the 27 patient cases reviewed, Dr. Husel used an override function on the hospital’s medication dispensing machine to access large doses of pain medications – including fentanyl.

Two additional wrongful death lawsuits were filed Friday. That brings the total to 21.

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