SGH patient accidentally given an overdose of anaesthetic 10 times the prescribed dose

[Onglai]

https://www.straitstimes.com/singapore/courts-crime/sgh-patient-accidentally-given-an-overdose-of-anaesthetic-10-times-the?utm_medium=Social&utm_campaign=STFB&utm_source=Facebook&fbclid=IwAR0wzKx1zVsN5gkMhrpyj9qmkUl70rw1CgNRtuhJm4AB9OCMqJ84-wOFHWU#Echobox=1545212369

 

SINGAPORE - An elderly patient warded at the Singapore General Hospital (SGH) was accidentally given 10 times the anaesthetic prescribed, but this did not appear to have directly contributed to her death, said a coroner.

On Wednesday (Dec 19), an inquiry into the death of Madam Chow Fong Heng, 86, revealed that she was supposed to be given 4.17ml of intravenous lignocaine per hour.

But a staff nurse, identified only as Staff Nurse C in court documents, mistakenly keyed in "41.7" into the IV Smart Pump used to infuse lignocaine into Madam Chow.

[Onglai]

But Coroner Marvin Bay said the overdose did not appear to have directly contributed to or hastened Madam Chow's death.

He said she had a history of ailments including hypertension and end-stage renal disease, and found that she died of a natural cause.

However, he stressed that there are valid areas of concern in this case.

Edited December 19, 2018 by Onglai

[Onglai]

He said: "Nurse C, in explaining her error, indicated that she had no experience and limited exposure to the pump machine, but was nevertheless allowed to operate it.

"She had, of course, made the gross error in calculations with regard to the amount of lignocaine administered, apparently confusing the application of units of 'milligram' and 'millilitre'... in giving Madam Chow a dose which was effectively 10 times the actual prescribed dose."

The coroner noted that SGH has acknowledged shortcomings in the training and assessment of the competency of its nurses.

He said: "SGH has informed the inquiry of steps taken to remind and reinforce the importance of strict compliance of requirements imposed in counterchecking where medications and sedatives are administered, and also in ensuring that nurses have the requisite competency and knowledge when tasked to administer medication to patients."

Madam Chow, who was on dialysis, was admitted to SGH on May 24, 2016, after a special site on her left arm created to facilitate the procedure was found to be red with pus. Her bodily discharges were later found to contain pathogens.

Six days later, she was found to be suffering from a rapid heartbeat and a doctor from the National Heart Centre then prescribed lignocaine to her.

Staff Nurse C made the mistake at 6.11am on May 31 that year, leading to the overdose. The Renal Intermediate Care Centre was informed of the error about two hours later.

Coroner Bay said: "In the event of severe overdosages of lignocaine, the affected patient could develop seizures and central nervous system depression. A severe overdose can contribute to morbidity and mortality."

However, Madam Chow, who died on June 2, 2016, did not show any signs of seizures expected with lignocaine overdose. A forensic pathologist found that she died of multi-organ failure and septicaemia (blood poisoning).

[aaur4man]

Wtf 

[Palladium92]

Must be from cecaland one

[beyond]

either is indo or pinoy... watever it is... name is not sexposed... means she is saved by the hosp... means gonna hav more chances to pwn us again..... 

side note... tats a major lapse.... not 2 3 times the stated amount but 10 times leh..... if she not sure y adminstrating it tat time nv ask other colleagues... whole ward only she meh..... 

[Coffee_O]

pinay? hope the deceased family belongs to 70% then all i can say is SB70

Edited December 20, 2018 by Coffee_O

[RoboCop]

That's gahmen hospital for you 70%. *slow claps