This article was published on December 29th, 2016
A hospital has conducted an internal negligence investigation after one of its patients died after being administered a fatal dose of medicine 10 times the prescribed amount.
The 57 year old patient, who suffered from muscular sclerosis, was admitted to hospital with pneumonia. The woman was struggling to swallow fluids and solids as a result of her MS and this cause food to get into her lungs and cause and infection. She was prescribed a stomach peg to enable her to eat and drink. It was also found after a full medical assessment that her magnesium levels were low and so as part of her treatment before surgery, she was given a therapeutic dose of magnesium sulphate via a drip.
A nurse miscalculated the number of vials that needed to be added to the saline solution which resulted in the patient receiving 10 times the recommended dose. A post mortem examination found that the patient had died from magnesium infusion as a result of tragic human error.
As a result of her death, the Hospitals Trust provided extra training to the nurses, apologised to the family and the medication is now supplied in ready-made packs rather than reliant on nurses to make the calculations.
The patients sister said: “I’m still bewildered how she was prescribed one thing and given something ten times the dose despite two people checking it.
“I did not have the chance to say goodbye. Had they done the right thing my sister would still be with us.
“The trust only apologised to me in a letter we received on December 19, the day before the inquest, in which they said it was completely their fault.
“However, I do have confidence that the changes they have made will help prevent further cases like ours.”
The patients other sister said: “My sister’s death was avoidable and preventable and was vulnerable.
“I cannot bring her back but I want to make sure this does not happen to anyone else.”
The Coroner said:
“To prevent this happening again, we have changed many policies and procedures. Now all intravenous magnesium is pre-prepared by pharmacists to prevent medication errors like this occurring.”
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