What Happened and How Could it be Prevented in the Future
Earlier this year, a grand jury indicted a physician in Columbus, Ohio for the alleged murders of 25 patients under his care at a facility known as Mount Carmel West. Although Dr. William Scott Husel, aged 43, had been terminated by the hospital system prior to the indictment, he was originally investigated in connection with up to 35 patient deaths. He wasn’t alone in the inquiry.5
Twenty-five nurses have been reported to Ohio state boards for possible review, and 23 employees have been terminated from the system, including five physicians, as well as nursing management and pharmacy team members. Additionally, the hospital CEO has resigned, as well as the chief clinical officer. Although the Mount Carmel West facility has since closed, and inpatients have been moved to alternate facilities, Mount Carmel’s Health System is still reeling from a scandal that rocked community trust at one of their main Ohio facilities.1
How could such a nightmare transpire? How could it happen in Ohio, a state that has borne so much tragedy from the opioid crisis in recent years? And how could multiple disciplines ignore overly large doses of fentanyl over a prolonged period (2014-2018), without any of the professionals becoming alarmed?
When the tale was finally told, it was a pharmacist who raised the alarm4 But in retrospect, someone should have noticed sooner. Fentanyl is often used for critically ill and/or ventilated patients, but never in such troubling doses that repetitive machine dispensing overrides are required. In retrospect, did these nurses not question why? Why would only one physician’s patients require such large doses of opioids for comfort care when no other patients warranted the same? What lulled these providers into a sense of ease when they should have been distressed?
Dr. Husel was originally investigated for the deaths of up to 35 patients at Mount Carmel, but prosecutors decided to narrow that range to cases where the fentanyl dosages were 5-10 times higher than normal. In one of those examples, the patient’s family stated they were told a family member would be removed from life-support. Shortly thereafter, a substantial quantity of fentanyl was delivered by the nurse. The patient, although unconscious, died within five minutes, depriving the family of time they had wanted at the bedside. The family questioned a need for any medication at the time of passing, given the patient’s advanced state.7
Indeed, many of Dr. Husel’s patients were considered by the physician to be terminal, but the patients’ families were not sure. A few families believed they were coaxed into a belief their spouse was hopelessly ill, although the symptoms were remarkably like previous illnesses that had been episodic and survivable. Others had little time to absorb the information they were provided, such as Christine. Christine Allison, whose husband Troy was involved in a truck accident, interacted fleetingly with Dr. Husel. She remembers him telling her, “Oh no, he’s dying, I’m 99.9% sure he’s brain dead.” Her husband expired approximately three hours after he arrived at the hospital. But Christine had doubts, wondering if Troy might have had a chance.2
The hospital involved, Mount Carmel Health System, “tipped off investigators after they began their own investigation.” No one other than Dr. Husel has been indicted, although nurses have been reported to their state board for review. It is not clear how many health professionals have been named in civil (wrongful death) suits at this time, 36 of which have been filed. Eleven hospital employees have been allowed to return to work as of this writing, with additional training related to their field of expertise.4
Dr. Husel has since sued his previous employer for breach of contract, as they have settled many of the wrongful death suits but have not provided him with attorneys or a defense fund for the criminal trial, which is scheduled to take place in June of 2020. As he has been indicted for murder, Mount Carmel Health System has offered they would not be expected to cover him for potential felony acts. Dr. Husel surrendered himself voluntarily to authorities in Columbus, Ohio8, and has surrendered his passport. He has pled “not guilty” to the charges before him. His license to practice medicine was suspended by the State of Ohio but is on appeal.
What can be done to prevent this in the future
But what about the nurses, who may lose their licenses and/or their livelihood based on individual actions in this case? Could this happen in another facility? How do we prepare nurses to think through the possibilities of this tragedy?
What happened at Mount Carmel Health System could be that nurses may become liberated to the process of dispensing overrides, simply via the frequency with which they were performing those actions. Every time a nurse performs an override in a dispensing machine and receives a warning, that should be an automatic STOP. STOP and think through the process of why am I performing an override? The machine is reminding the nurse a dose is outside a protocol that is a mechanism for patient safety. In one of the alleged fentanyl “murders”, a nurse performed a dispensing override, had a second nurse sign off, then walked to the patient bedside and injected a lethal amount of fentanyl into the patient. The patient died within 30 minutes. What is surprising is that neither nurse stopped to question the dose, the intent, their actions, or the horror of what they had performed.
This is akin to the sequence of missteps that led to a patient receiving a paralyzing agent in December 2017, when patient Charlene Murphy received Vecuronium as opposed to Versed, and a nurse was charged with elder abuse and reckless homicide. Overrides on dispensing cabinets should happen only in rare emergencies. When they become common occurrences, tragedies may follow.3
Subsequently, while investigating actions of nurses and pharmacists at Mount Carmel Health System, it was discovered that the hospital had no definitive system in place to monitor either the total number of dispensing overrides that were being performed or by which specific employees. If the hospital had such a system, they might have discovered the inflated doses of fentanyl and untimely patient deaths sooner, as some patients died mere moments apart. In fact, one death occurred after a complaint was filed against Dr. Husel.3
Ultimately, nurses caring for patients receiving opioids need to be informed regarding dosages as well as the plan of care. Dr. Husel, an acute care physician with a certification in anesthesiology, often acted as planner in guiding patients near the end of their lives, frequently ordering 1000-2000mcg of fentanyl at a time. It is amazing no physicians questioned him when he believed these amounts were needed to “assure patient comfort”, especially given the advanced condition of many of the patients. Nurses should be aware of goals for their patients. Is the family included in the plan, which did not always seem to be the case with patients of Dr. Husel?
Families in the aftermath of the fentanyl deaths expressed remorse, sadness, and conflicting emotions, including surprise. David Austin is one of those family members. His wife of 37 years died at Mount Carmel Health System thirty minutes after she was injected at 11:23 PM with fentanyl. A pharmacist approved the dosage of drugs his wife was given. Dr. Husel told him his wife would not survive, that she was too ill, but David wasn’t sure. He knows the medication was obtained by override, just like many of Dr. Husel’s other patients. David believes the system needs to change, so it has.3
Mount Carmel Health System has made several safety changes related to opioids, but the most important as related to this case has to do with system overrides and fentanyl dosing. Fentanyl dosages over 250mcg will no longer be stocked in dispensing machines and will not be available on units. Mount Carmel is also working on a process for auditing dispensing machines at frequent intervals to detect overrides quickly, as well as determine medication discrepancies.3
As for nurses, it is extremely important to process exactly what you are doing each time a medication is accessed for patient care. Is this an appropriate dose for this patient? If an override warning is received, why? Take time to think about the safety guardrails built into the dispensing machine. An override is for your protection, but more importantly, for the safety of patients. Years of research went into those guardrails. Do yourself a favor, heed the warning, ask questions.
People like David Austin and Christine Allison will thank you.
- Amp.usatoday.com “Deaths, excessive doses lead to firing of 23 workers at Ohio hospital.” Franko, K., July 12, 2019.
- CBSnews.com “Ohio doctor charged with 25 deaths allegedly ordered fentanyl doses up to 40 times too strong.” CBS Interactive Inc., June 6, 2019.
- Dispatch.com “Could Mount Carmel deaths have been prevented?” Viviano, J., Sullivan, L., & Wagner, M., updated July 14, 2019.
- Drugtopics.com “Pharmacists among those fired in hospital fentanyl deaths case.” DeBenedette, V., July 12, 2019.
- Medscape.com “Murder by opioid: The case of the Ohio doctor charged with 25 counts of murder.” Rice, L., October 1, 2019.
- Mobilereuters.com “Ohio hospital where doctor accused of opioid murders worked settles lawsuit.” Goldberg, R., accessed 10-6-2019.
- NBCnews.com “Ohio doctor charged with 25 counts of murder, accused of prescribing excessive doses of painkillers.” Ortiz, E, June 5, 2019.