November 15, 2009 by admin
Filed under Top News
Written by our Correspondent
Kandang Kerbau Children and Women Hospital (KKCWH) has gone on a PR overdrive to limit the damage from the a medication mistake which could have dire circumstances for the two patients who receive a massive chemotherapy drug overdose.
Two patients – Ms Yip Poh Hung and Mrs Ng L K, received chemotherapy drugs from an infusion pump in just a few hours instead of a few days.
The mistake was discovered by Mrs Ng who informed the hospital. Frantic calls made to the only other cancer patient to have been fitted with an infusion pump that day – Mrs Yip, who was recalled back to the hospital at once.
Mrs Yip received a potentially lethal dose of 5-fluorouracil (5-FU) in just five hours instead of over 5 days.
Mrs Ng was more fortunate – though she was given the drug in 3 hours, the drug she is on can actually be given in just 15 minutes.
KKCWH called a press conference the next day to explained what happened. There was full disclosure of the case and there appeared to be no cover-up.
The state media, for its part, had been trying desperately hard to ameliorate the severity of the error.
The Sunday Times even wrote that two things worked in the “favor” of Mrs Ng:
“But two things worked in her favour – the mistake had been discovered just 10 minutes after she had received the dose, and an antidote to reverse the wrong dosage was available, although it is still in the experimental stage.”
According to a senior medical oncologist Dr Soh Lay Tin, Mrs Ng is not out of the danger yet and her condition needs to be monitored closely over the next few weeks.
KK Women’s and Children’s Hospital used two types of infusion pumps – one which is calibrated in hours and the other in days.
The pharmacists who programmed the women’s pumps that day got the calibration mixed up, so instead of three and five days, they became three and five hours.
It is not revealed if the pharmacists are fresh graduates or if they are trained adequately to handle the infusion pumps.
KKCWH claimed that following the error, it immediately changed the way its chemotherapy infusion pumps are used to prevent another similar mistake from repeating itself.
Meanwhile, the two pharmacists who were responsible for the error have been given “light duties”. They are helping with investigations. It is not known if they will be sacked from the hospital.
Medication errors like this are not uncommon in Singapore’s public hospitals where the junior doctors and nurses are often overworked and stretched to their physical and mental limits.
Such cases are usually not reported in the press and are resolved quietly “internally” without much of a hooha.
House officers on night calls can sometimes work 36 hours continuously without sleep.
Singapore faces a perennial shortage of doctors especially in the public sector where low pay and long working hours have led to an exodus of senior medical officers upon expiration of their mandatory 5-year bond with the Singapore government if they are local graduates.
To deal with the manpower shortage, the Ministry of Health has turned to recruiting foreign doctors from overseas especially from India and the Phillipines.
Source: The Temasek Review