NHS critic killed by medical error
Posted by GruntDoc on 27th September 2004
So, irony isn’t just for stateside medicine:
Telegraph | News | Patient’s liver ’saturated’ with iron after hospital confusion over dosagePatient’s liver ’saturated’ with iron after hospital confusion over dosage
By Daniel FoggoA critic of declining standards in the National Health Service died after being given a large overdose of iron by a hospital doctor who did not read the instructions on the drug’s label properly.
Carys Pugh, 63, a former president of a patients’ association in Wales, was taken to casualty at the Royal Glamorgan Hospital after the blunder turned her skin brown and “saturated” her liver with iron.
While she fought for survival in hospital for seven weeks, Mrs Pugh suffered a heart attack and contracted deep vein thrombosis in both legs, a chest infection and then E.coli. Finally, she suffered a second heart attack that killed her.
When her daughter, Hawys Pugh, complained to the hospital authorities about what had gone wrong she was told that the doctor who had carried out the routine infusion for suspected anaemia had found the instructions difficult to decipher and that he had only read half of them.
“They told me that because the text was in two columns instead of one, the doctor just read the section on how much to give, but didn’t bother reading the rest which said over what duration it should be given,” Miss Pugh said.
“Instead, he just put the entire dose into her system in one go. They suggested it was the manufacturer’s fault and said they would be contacting them.”
…
(emphasis added).
Medication errors happen everywhere, it’s human nature. It’s human, but probably not terribly professional, to blame a manufacturer for having not bothered to read the instructions.
cross posted on TheLingualNerve
thanks to reader Jim for the steer
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