Details of the incident
A 64 years old man was admitted to an emergency ward of North District Hospital in Sheung Shui, Hong Kong on April 23, 2018. The reason for the hospitalization was abdominalgia, vomiting and weakness in the lower limbs of the patient. After medical examination, he was initially diagnosed with diabetes and cardiovascular disease. However, further diagnosis, conducted on the next day, confirmed that the patient also had pancreatic cancer, which had spread to the liver (Yau & Cheung, 2018).
After receiving in-patient care for his condition, the patient was appointed to be released from the hospital on May 4, 2018 with prescribed medicine for diabetes, cardiovascular disease and high blood pressure. I was asked to hand the said medications to the patient before he leaves the hospital, but when I walked into the ward, he was away to get discharged. That is why, I decided to put them in the drawer near his cot, thus, he can collect them when he is back. However, the patient left the medications in the drawer and went home without them. Hospital staff, including me, did not notice this mistake as well.
Several days later, on May 8, 2018 a family member of the patient visited the hospital to ask if he had been prescribed with any medicine but got a negative reply. Yet, on May 17, 2018 the personnel of the hospital came upon an untouched drug package in the same drawer, where I had previously put it. On the same day, the patient lost consciousness at his home and was taken to the ward. Unfortunately, the CPR attempts to help the patient failed, and he was declared deceased. The official cause of death was proclaimed to be cancer of the pancreas with metastasis.
Causes of the incident
The possible cause of this incident could have been my decision to put the vital medicine in the drawer without telling the patient about it. I thought, that he would be informed about the fact that he needs to collect the drugs before the discharge. Furthermore, I was sure that the patient would check his drawer carefully before leaving, thus, he would not forget his personal belongings in the ward. From my standpoint, that way he was supposed to come upon the drug package I left there. Apart from not handing the medications directly to the patient, my fault was ignoring the circumstances, in which he was a senior citizen and was in a rush, while discharging from the hospital. Additionally, I should have inspected the drawer myself afterwards as well.
Moreover, another cause, that could have led to this unfortunate incident is miscommunication between the staff of the hospital. In my opinion, the damage might have been reduced, if the inquiry of the patient’s relative regarding his medicine prescription was responded with proper information. Moreover, when the forgotten drug package was finally found, it should have been reported to the management. Those with heart and blood pressure problems have to strictly follow the regimen, since skipping the medication intake could outcome in deterioration of the condition. That is why, although given a chance to notice the medical error earlier, the personnel were not able to use it to prevent the incident.
Recommendations for prevention of recurrence
To avert similar incidents in the future, the hospital should align another strategy of patients’ discharge procedure. From my point of view, a doctor should write out a prescription list and hand it out straight to a patient or their relative, thus, they can receive medication in the hospital pharmacy by themselves. This policy might be beneficial for patients, as they can get additional information about their medication from the pharmacist if they need it. More than that, it will definitely exclude the risk of forgetting the drugs in the drawer of the ward.
Furthermore, we as the staff of the hospital, have to be more considerate and involved. If there are any doubts, it is always better to double-check everything, whether it be electronic patient record system, where the data about all the registrants’ prescriptions is held, or a drawer of a discharged patient. Also, it is important to keep the management of the hospital updated on the current situation inside of it, and report all the happening incidents, even if the personnel will risk facing punishment for them.
Reference
Yau, C., & Cheung, E. (2018). Hong Kong’s North District Hospital to probe patient death after nurse forgets medication. South China Morning Post. Web.