Renowned Cancer Researcher Given Fatal Dose of Fentanyl Instead of Fluids in hospital
David Boothman helped pioneer a promising approach to fighting cancer by turning diseased cells against themselves in a process he dubbed the Kiss of Death. In 2017, Boothman was drawn to Indiana to serve as the inaugural Sid and Lois Eskenazi Chair in Cancer Research at the Indiana University School of Medicine and Associate Director of Translational Research at the Simon Cancer Center. Boothman will never get the opportunity to see if his research translates into saving lives.
As Boothman recovered from a stroke at the age of 61, a nurse at the Sid and Lois Eskenazi Hospital in Indianapolis mistakenly administered a massive dose of fentanyl (a synthetic opioid nearly 100 time stronger than morphine) instead of a benign hydrating solution, causing his death a week later on November 1, 2019. The fentanyl depressed his blood pressure, causing brain damage that pushed Boothman into an irreversible coma. He died from respiratory failure following the fentanyl overdose and the coroner ruled his death an accident.
Officials denied the mistake caused Boothman’s death, but acknowledged the medical error. Boothman’s widow, Dr. Sue Strickfaden, has been in a malpractice dispute with the hospital, but last week the hospital proposed a settlement with Strickfaden. The offer came after IndyStar interviewed parties.
Boothman’s death came after a “tragic circus of errors” that occurred during his stay at Eskenazi. “The main issue is how lethal and dangerous fentanyl is as a medication, not just on the streets but even in the hospitals, and how little the very people that are in the hospital handling it actually seem to have been trained,” Strickfaden said.
Eskenazi Health spokeperson, Michelle O’Keefe, stated: “In the unfortunate and infrequent circumstance when a medical error does occur, we immediately conduct a thorough review to determine the cause of the event, learn everything that we can from the situation, and develop specific action plans to reduce risk and further improve patient safety.”
An associate professor at IU who worked with Boothman, Lindsey Mayo, stated “He was starting a whole new group to work on a specific area, which we didn’t have at IU, and he was pivotal, because he has such an infectious personality, in getting a lot of these junior people to come here.” “In my opinion, Dave was a superstar,” said Marc Mendonca, Director of Radiation and Cancer Biology and Associate Vice Chancellor for Research in the IUPUI Departments of Radiation Oncology & Medical and Molecular Genetics. “In the last few years he hit the big time. He published major papers. But he worked many, many years to get there. And then, suddenly, all the grants came and, you know, he was rocking.” Strickfaden said he was involved in research projects that attracted more than $20 million in grants.
On Oct. 17, he complained about fatigue and balance problems to Strickfaden, who had returned to Texas to handle their home sale there. An Indianapolis colleague called an ambulance the following day to take Boothman, who was unable to get up, to Eskenazi Hospital. Over the next two days, Boothman’s condition stabilized. He began speech, physical and occupational therapies, according to Woody, the attorney representing Strickfaden. As he continued to improve, his diet was advanced on Oct. 20 to solid foods.
A little after 11 p.m. on Oct. 25, a nurse covering for Boothman’s primary nurse responded to an alarm going off on a medication pump next to Boothman’s bed. An IV bag of Lactated Ringer’s solution, a common hydrating fluid, needed to be replaced. The nurse obtained a new bag of the solution and hung it on the pole along with other medications also attached to the pump. One of those bags contained the fentanyl, which had been discontinued earlier in the day.
The nurse said in a deposition that she scanned the solution and a barcode that came up on the pump before restarting it at 11:24 p.m. The steps were part of a confirmation procedure intended to track medications and catch errors. But there was a gap in the fail-safe system.
She had attached the hydrating solution to one channel on the pump, but mistakenly pushed the start button for another channel — the one attached to a bag of fentanyl. The pouch holding the drug he had been off since earlier in the day remained attached to the pump nearly 12 hours later.
Because the mix-up went unnoticed, over the next 69 minutes Boothman received 1119.4 mcg of fentanyl. That was nearly 20 times the largest dose he had received for sedation before it had been discontinued. A doctor in Ohio was charged with murder last year after prescribing patients 500 mcg of the drug. The error was finally discovered at 12:33 p.m. Oct. 26. But Boothman wasn’t given Narcan, which can counter the effects of opioid overdoses. A doctor didn’t come to his bedside until 2 a.m., according to the chart. Even then, no Narcan was administered as Boothman’s blood pressure plummeted to a level too low to provide an adequate oxygen supply to his brain and other organs.