A panel investigating the death of an 84-year-old patient in North District Hospital advised a review of procedures on Friday.
The elderly woman – who was in the terminal stage of metastatic malignant melanoma (a type of skin cancer) – was admitted for suspected abdominal viscus on Nov. 18.
She received an intravenous fluid infusion for hydration and nutrition set at 83.3ml/hour, and morphine set at 3.3ml/hour for pain relief.
However, when a trainee nurse was asked to replace one of the bags, the two drips were mixed up, leading to a morphine infusion of 83.3ml/hour, 25 times the prescribed amount.
The nurse supervising the student did not notice the error for another hour.
When the mistake was finally realised, the morphine infusion was stopped immediately and the patient was kept under close observation. However, she passed away five hours later.
The investigation concluded that two factors impacted the accident: the medical student’s mistake in mixing up the infusions lines and the supervisor’s failure to notice.
As a result, the hospital has been recommended to review its clinical supervision arrangements and to reinforce its competency assessment of trainee nurses.
“Appropriate disciplinary actions will be considered according to prevailing human resources policy,” a spokesperson for the hospital authority said. “The hospital has explained the investigation findings to the family and also extended sincere apologies again.”
