Double jeopardy by negligent Docs in KKH

[apollo]

Two patients got days' worth of cancer drugs in hours
Salma Khalik
Thu, Nov 12, 2009
The Straits Times

HUMAN error at KK Women's and Children's Hospital (KKH) led to two cancer patients being given more chemotherapy drugs than they were supposed to get.

They had the drugs injected into them in a matter of hours instead of over several days. One of them is now in a potentially serious situation.

She has been given an antidote to counteract the effects of the overdose, but it will be at least a couple of weeks before doctors can tell whether any of her organs have been damaged by the highly toxic drugs in her bloodstream.

http://news.asiaone.com/News/the%2BS...12-179378.html

[Ddeath]

Woah... world class indeed. Hopefully the patients are ok. They should sue the pants off them to make sure they don't be negligence again!!

[athena]

Not the first. I know of quite a few medical mishaps. Anecdotal perhaps but the fact is that no one in singapore bothers to sue for medical malpractice. In the US, all this would be litigated.

[radioactive28]

Anyone read the actual article? What led to the error?

[highdiver_2000]

Anyone read the actual article? What led to the error?

According to ST, Pharmacist program the wrong rate of delivery. Another pharmacist doing cross check missed the error.

Note KKH really jumped through lots of hoops in one weekend.

[sigh]

Sure will sue one. but wont be like US.

[auron]

when did this happen? recently or some time ago?

[fimo]

Sadly, dosing and prescription errors happen way more frequently than is reported in the news.

[radioactive28]

Sadly, dosing and prescription errors happen way more frequently than is reported in the news.

According to ST, Pharmacist program the wrong rate of delivery. Another pharmacist doing cross check missed the error.

Note KKH really jumped through lots of hoops in one weekend.

If that's really the case, would changing the system to two independent entries be useful? Have two different people enter the (supposedly) same data independently, let the computer compare and raise a flag if they don't match. Could even do it by having the same person enter the data twice at different times. It introduces a bit more work for the pharmacists, but an improvement could be one live saved.

[Silverelf]

If that's really the case, would changing the system to two independent entries be useful? Have two different people enter the (supposedly) same data independently, let the computer compare and raise a flag if they don't match. Could even do it by having the same person enter the data twice at different times. It introduces a bit more work for the pharmacists, but an improvement could be one live saved.

The system would need a total overhaul, as in sourcing for machines which work this way and I don't think there is any on the market. It's not exactly computerised.

[radioactive28]

The system would need a total overhaul, as in sourcing for machines which work this way and I don't think there is any on the market. It's not exactly computerised.

That's a little surprising. So the measuring and dispensing has been hand-done all this while, even at the scale of a hospital?

[Silverelf]

That's a little surprising. So the measuring and dispensing has been hand-done all this while, even at the scale of a hospital?

No, I'm just saying that the machine being used probably cannot take double inputs.

[fimo]

That's a little surprising. So the measuring and dispensing has been hand-done all this while, even at the scale of a hospital?

Depends on what you're talking about. There are so many different kinds of drugs, so many formulations, so many hospitals, clinics and dispensaries. Did you think there was this big machine that automatically reads electronic prescriptions and puts your meds together? It's really quite a manual process - pills, tablets, powders, solutions are mostly in bulk that have to be counted/portioned out and packed for the patient.

Chemotherapy is administered through a computerised pump, which dispenses a fixed rate of medication determined by the doctor. The pharmacist is the one who reconsitutes the medication (diluting the drug with saline etc), and then inputs the rate into the pump. Quite a few steps and potential sources for error.

[Lucien]

What she said... There's no master system where a doctor can type in a course of treatment in one end, and some machine on the other automatically knows what to do.

And mistakes with infusion pumps are, I think, more likely to happen than anyone would like. The syringe isn't built in, for obvious reasons, so you'd have to be sure that the infusion pump is matched with the right syringe since what it does is it depresses the plunger at a set rate and can't actually measure the fluid flow. Then there's the setting of the rate - some manufacturers might have a toggle to switch between /h or /day instead of allowing the operator to set it in hours or blocks of 24 hours. Or they might have two seperate models for /hour and /day delivery systems but confusingly make them look exactly the same...

[radioactive28]

Oh, guess I simplified things a bit too much...