In June 2020, a man received a dose of chemotherapy at Haukeland Hospital that was 10 times as high as it should be. Helse Bergen and Sjukehusapotekene i Vest must now pay a total of NOK 2.6 million in fines after the serious incorrect medication. Neither the doctor nor the hospital pharmacist discovered the error until 80 percent of the dose had been set, and the man died as a result of the incorrect medication. – This tragic incident is not the result of an accident, but is due to deficient routines both at the hospital and at the hospital pharmacy, says public prosecutor Rudolf Christoffersen. Case against the doctor closed The hospital used manual rounding of the chemotherapy doses. The public prosecutors in Hordaland, and Sogn og Fjordane believe that the hospital was aware of the risk of incorrect treatment associated with this method. The CEO of Helse Bergen, Eivind Hansen, has previously apologized for the incident. The cancer ward and the hospital pharmacy used the electronic system Cytodose to calculate the dose of chemotherapy the patients should receive. Then the doctor himself had to round off the dose. The doctor who gave the dose to the man calculated incorrectly in rounding off the dosage. The pharmacists who were to check the dose at the hospital pharmacy did not respond either. The public prosecutor believes that the two companies ran an unacceptably high risk on behalf of the patients, and that the dangers of manual calculation have been known long enough that they should take action to prevent this type of error. – The routines, procedures and risk assessments that have been made have not been good enough, Christoffersen says to news. According to the public prosecutor, both Helse Bergen HF and Sykehusapoteket have neglected their duty to work with quality improvement and patient safety. The doctor who ordered the chemotherapy has had formal status as a suspect, but the case has now been dropped. – The error that has occurred here is due to a lack of routines and procedures that capture human errors, and it is a responsibility that lies with the hospital, Christoffersen says. Did not receive proper health care After the incident, the county doctor in Vestland opened an inspection at the cancer ward at Haukeland and the hospital pharmacy. The state administrator in Vestland concluded that the man did not receive proper health care, and that he died as a result of the dose. – There are many different conditions that have not been as it should be. It is the whole that has led to the tragic result we saw in this case, said assistant county doctor in Western Norway, Sjur Lehmannhan, to news.
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Helse Bergen and Sjukehusapoteka i Vest will be fined for incorrect medication – news Vestland
