Medical Error

Disturbing news has emerged today from an inquest into the death of an elderly man at the City Hospital, Belfast in 2005. A junior doctor at the hospital gave him an overdose of insulin (he administered 100 times the correct dose) causing the man’s kidneys to fail and he died a short time later from a heart attack. The patient had undergone surgery for an aneurysm (blood clot) in the knee and while he had a number of life threatening conditions, the inquest found that his death was most likely attributable to the medical error. The junior doctor, in a letter to the coroner, stated that he had not received any instruction in the handling of insulin. There was no mention of an apology to the family of the deceased.

This incident does little to inspire patients’ confidence in the medical profession. It begs the question as to why a junior doctor who was clearly ‘out of his depth’ in prescribing medication, should have failed to seek advice from a more experienced colleague – a senior nurse or doctor. The medical profession should have come out today with their hands up to explain the circumstances of this case, and to apologise. We were simply told that the junior doctor in question no longer works within the UK hospital network. That is not good enough! Patients need reassurance if they are to put their trust in the medical profession. Is it any wonder that the practice of medicine is now hugely threatened by litigious claims from patients/relatives who are dissatisfied with the treatment received? An apology is so often all that is required.

This has reminded me of an incident I experienced as a patient many years ago. I was undergoing intensive antibiotic treatment at the time with two different antibiotics. One antibiotic was administered in diluted form via an intravenous drip. The second antibiotic (the name of which I can no longer recall) had to be administered undiluted, by injection. This drug was very hard on veins and in order to prevent it collapsing the veins, it had to be injected very, very slowly into a cannula in my arm. Each treatment with this particular antibiotic involved two syringes – one large one which contained a harmless solution to ‘flush’ the vein out both before and after the treatment, and one smaller syringe which contained the antibiotic. The night nurse duly arrived with her injection tray and proceeded to flush out my cannula/vein with the first syringe. Within seconds I experienced severe pain travelling up my arm and I was completely consumed by it’s intensity. Very quickly though I realised that the nurse must have mixed up the syringes and once I’d recovered my senses, a quick glance at her injection tray confirmed my suspicions. By this stage the nurse had become very flustered and it was clear that she too realised her mistake. When the pain finally started to ease I told the nurse of my suspicions and to my horror she completely denied the error. The evidence was there to see but she was having none of it. She continued to insist that what she’d injected was the ‘flush’ solution. The fact that she looked like the ‘She Devil’ (remember that TV programme?) did little to improve my confidence in her and I refused to let her to continue to administer my treatment. It was so obvious that she had made a mistake but she was never going to admit that fact. She left my bedside to telephone the house doctor to request the insertion of a new cannula as the vein had collapsed from the abuse received. I never saw her again.

I considered making a formal complaint about her but I never did so because I was concerned that it would impact on my overall treatment in the hospital. As a patient, you feel somewhat vulnerable when in hospital and tend to put up/shut up rather than cause a scene. That nurse was very lucky that she didn’t cause more harm through her carelessness. She could have killed me had the drug been a more toxic one or had I been a frail, elderly patient who may not have been able to withstand the shock to the system. I regret that I never complained officially about her and I can only hope that she learnt something from her mistake. After today’s news though, I’m not so sure.

Do you have a view on this? Please let me know what you think by leaving a comment on this post, or if you prefer, you can email me at biopsyreport@gmail.com

9 Responses to Medical Error

  1. Nonny says:

    I would definitely have reported her, I know people maintain that we all make mistakes but they have a significant amount of responsibility if they can’t handle that they shouldn’t go into that profession. I can’t believe she denied it the bitch. You should have complained, but when you are sick all you think of is trying to get better and avoiding rocking the boat in the process. Retrospect is lovely!

  2. Steph says:

    You’re on the ball Nonny! I agree, retrospect is a fine thing.

    Sorry to read of your car incident yesterday. I hope you feel a little better anyway after getting it off your chest. I’m sure you’ll drive again, in time – don’t let that guy get the better of you.

  3. Harry says:

    Ouch steph thats terrible, I would probably have complained at a later date if it was me.

    Stupid thing is I’m guessing you wouldn’t have minded at all if she’d admitted her mistake and was genuinely sorry for it. Let’s hope she learnt from the experience anyway.

  4. Steph says:

    Absolutely! – denying it only made things worse than they already were – and it didn’t help either that she looked like the back of a bus! However she ‘got off’ on this occasion, we can only hope that it was a wake-up call for her.

  5. Bendygirl says:

    I would probably have done exactly as you did as a patient, felt too vulnerable to push things too far whilst in hospital. I don’t know why there is such a strong culture of refusing to admit mistakes and make a simple apology, I’m sure it would prevent many negligence actions being brought.

    I’m another blogger with EDS btw, I’d like to link to you if that’s ok? Bendy Girl

  6. steph says:

    That’s fine with me Bendy Girl. Thanks for your comment btw. I hope my story has been of some help to you? EDS is certainly to blame for an awful lot!

  7. Wandering Odysseus says:

    An easy mistake to make at the end of a long shift. I have done a similar thing myself. However, the only thing to do is admit what has happened, appologise profusely, either assure the patient that no harm will come to them (or, if you are not sure, tell them that you will immeadiately find out about any potential effects).

    Mistake: completely forgivabe.
    Refusing to take responsibility: imorral.

    There is no science to flushing a canula, absolutely anybody can do this, but after x amount of times 100% of people will make this error. What makes the difference between a technitian and a doctor is being able to accept responsibility for what you are doing and deal with any consequences.

    The nurse in question was giving IV drugs and therefore had been ‘IV trained’, she was therefore more than capable of putting the canula back in herself, but I note she chose to bail out and call the doc.

  8. steph says:

    Thanks WO – you’ve helped to restore my confidence in the system. No-one is perfect but denying an error is unforgivable. She was very lucky that it was only a vein (and not me) that collapsed from the abuse received! As regards re-siting the cannula – even if she’s offered to do it I don’t think I’d have let her near me – I was more than happy to see the back of her!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: