BUTLER TWP — A medication mix-up at Butler Memorial Hospital, which involved some emergency room patients being given painkillers seven times stronger than the ones doctors prescribed, prompted a review of policy and procedures at the hospital.

Dr. David Rottinghaus, medical director of the emergency department, said the review was broad and involved “about every imaginable department within the hospital.” Rottinghaus said both he and state officials were satisfied with the speed of the hospital’s response once it learned of the mistakes.

A state report says the incorrect injections occurred between Aug. 24 and Aug. 31, and involved 18 doses of hydromorphine, also known as Dilaudid, that were given to patients instead of doctor-prescribed morphine sulfate.

Hospital officials said no patients were harmed, and the errors were reported to state officials as soon as hospital officials became aware they had occurred.

The medications are “look alike-sound alike” drugs because of their similar packaging and use, but differ widely in strength. Dilaudid is seven times stronger than morphine, according to a hospital pharmacy technician cited in the state report.

The errors came after pre-filled syringes of the stronger Dilaudid were put into medication dispensers that had already been partially filled with the weaker morphine sulfate. When patients were prescribed morphine sulfate, the report said, staffers used the Dilaudid without verifying the medication name on the syringe.

“The staff failed to ensure patient safety and meet the needs of patients,” the state’s report says.

The hospital said its review determined that only one machine in the emergency department was affected, and only patients in that department were given the incorrect injections.

“We immediately reviewed all available information regarding patients who may have been impacted. The review revealed nothing to indicate that anyone was harmed in any way,” hospital officials said in a written statement.

According to a Department of Health report, state officials learned of the mix-ups on Sept. 3, the same day the hospital instituted an “immediate action plan” that called for education and counseling for the staff members involved.

Rottinghaus said the medication boxes have been used by hospitals for years to secure and track doses of potent narcotics and other high-risk medications. The use of bar coding, which helps hospital officials track medication, also can reduce instances of misidentified medication.

“What it has really caused us to do is take a step back and look at our processes,” Rottinghaus said of the incidents. “As with any technology, there’s a give and take. There’s always potential for error, but we try and mitigate that by our processes.”

The hospital’s plan also requires the development of a policy detailing who is in charge of medication dispensing machines when the director of pharmacy is not available.

“We were alarmed by this unfortunate incident and it has prompted us to examine every aspect of our medication distribution and administration process,” hospital administrators said in a written statement.

The administrators said state officials visited the hospital on Oct. 30 and were satisfied with the hospital’s plan and had “no further recommendations for improvement.”