COLUMBUS (WBNS) – Mount Carmel Health System will have to pay $477,000 in fines, hire a consultant and be potentially subjected to increased scrutiny as part of a settlement agreement reached with the state in wake of the patient overdose scandal – according to records released Wednesday by the board of pharmacy.
Two Mount Carmel pharmacists will also have to pay fines and receive continuing education courses in areas like palliative care, end of life therapy and medication safety, according to documents reviewed by 10 Investigates.
The state board of pharmacy announced the two pharmacists – Nathan Kochheiser and Gregory White – failed to conform to the standards of care by verifying drug orders for large doses of fentanyl order by Dr. William Husel.
Kochheiser was accused of approving two doses of fentanyl – one 500 micrograms and another 400 microgram dose – that were given to a patient 15 minutes apart noting that it was “compliant with the standard of care.”
In a separate incident, Kochheiser was also alleged to have approved a dose of 1000 micrograms of fentanyl, 10 mg of midazolam and 10 mg of hydromorphone 19 minutes after another pharmacist had approved an identical dose for a patient.
The patient received two rounds of medication and died within 15 minutes. Kochheiser could not be reached for immediate comment.
Pharmacist Gregory White told 10 Investigates “no comment,” when reached by phone Wednesday.
The board accused White of retrospectively approving an order of 1,000 micrograms of fentanyl be given to a patient on December 5, 2017. The documents state that “you spoke with the physician who issued the order, Dr. Husel, who informed you that he ordered drugs were for palliative ventilator withdrawal.” White was also accused of retrospectively approving drug orders for two additional patients – including one who received 2,000 micrograms of fentanyl.
According to the settlement documents with the board of the pharmacy, the pharmacists neither admitted nor denied fault but the board alleged it had enough evidence to sustain the allegations.
The hospital was accused by the board of pharmacy of failing to provide appropriate supervision and control of the automated medication dispensing machines. Records provided by the board of pharmacy show that nurses used the override function on the machines to bypass the pharmacy and gain easy access to the drugs with 28 patients “beyond the parameters of the policy, contributing to patient deaths.”
Mount Carmel released a statement to 10 Investigates Wednesday:
“We respect and appreciate the Board of Pharmacy’s efforts to finalize an Agreement and help ensure such events never happen again.
Mount Carmel has taken the following steps to improve medication safety, including:
- Establishing a policy to reduce verbal and phone orders
- Limiting overrides to only emergency situations
- Reviewing overrides per the American Society of Health-System Pharmacists’ best practice recommendations
- Setting maximum doses for pain medication in our electronic medical record (EMR)
- Establishing an escalation policy for deviations in our pain medication protocols
We will continue improving our already high-quality care, because there is nothing more important to us than our patients’ safety and their trust.”
None of the nurses or pharmacists named in earlier versions of the wrongful death lawsuits were criminally charged. Twenty-five nurses could still face discipline from their respective state board.
Dr. William Husel was fired by the hospital in December of 2018, accused of ordering what the hospital described as “excessive” or “potentially lethal doses” of prescription painkillers. All told – the hospital identified 35 patients who were affected and has paid out more than $13 million to settle wrongful death lawsuits filed by the patients’ families.
Husel has also been charged with 25 counts of murder. He’s pleaded not guilty. His criminal defense attorney told reporters after his initial appearance last year that Husel was providing comfort care to patients in their final moments of life. His medical license has been suspended and he awaits a June trial.