What was supposed to be a routine treatment for healthy women in the 60s turned into a nightmare. – I remember nothing of what had happened when I woke up in intensive care. I was terrified, confused and sick, she says. news knows the identity of the Sunnmør woman, but she does not wish to be named. Always need hospital care The woman lives with a type of blood cancer that requires her to go to the hospital for treatment at all times. In September last year, she was admitted to Ålesund Hospital for treatment due to complications from the disease. But an error occurred that could have had even the worst imaginable outcome. – I survived by luck and because of quick-witted and competent nurses. Not because of the procedures and routines of the department, she says. Mixing up the medicines The woman was supposed to receive the blood-thinning drug “Heparin”, which prevents the blood from coagulating, but instead she received a fatal dose of insulin into the central venous catheter. This led to her being found unconscious with an extremely low amount of sugar in her blood. According to a notification from the hospital to the Norwegian Health Authority, there was a mix-up of the two medicine bottles. – It is deadly serious, says the Sunnmør woman. She says that this was a big burden for the whole family. The woman received insulin via a venous catheter in her neck. Photo: Tuva Tagseth / news Did not follow procedure The hospital notified itself of the incident to the National Health Inspectorate, which in turn forwarded the case to the State Administrator in Møre og Romsdal. The state administrator asked the health authority to follow up on the case and find measures to prevent the same thing from happening again. The health authority does not wish to be interviewed, but write some answers in an e-mail. – The procedure for self-checking and double checking was not followed, writes section manager for cancer and palliation in Ålesund, Liv Ipsen. She confirms that the patient could have died if the error was not discovered in time. Due to the incident, several measures have been implemented in the department. Implemented measures Humalog (medical insulin) in vials has been removed from base stock. Each patient must have their own insulin pen. (In the past they have had joint pens for drawing up lying in the medicine room) The procedure for double checking of injections and infusions of Heparin must be followed. In the blue box in the medicine room, there should now only be open bottles of Heparin 100U/ml marked with the date and time. Vials with Heparin 5000U/ml are removed from the medicine room and base store. Furthermore, Ipsen writes that, in addition to measures, it has been important to follow up those involved in the case, both patients and employees. – We want to have a culture where deviations are reported in order to be able to improve the system, to minimize risk and to prevent similar incidents from happening again. The discrepancy has been raised in the quality council and shared with other section managers so that other departments can also learn from the incident, she writes. Ålesund hospital changed several routines after the incident. Photo: Øyvind Sandnes Result of poor routines The woman who was exposed to the wrong medication emphasizes that she does not blame individuals for the incident, but says that it was a result of poor routines in the department. – What do you hope will happen now? – When it comes to intravenous medicine with different active ingredients and vials that are similar, they cannot stand together. Then of course there must be double checking, she replies, and adds that she hopes that the new routines will prevent others from experiencing the same thing.
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Due to a mix-up of medicine glasses, the woman from Sunnmøre received the wrong medicine – news Møre og Romsdal – Local news, TV and radio
