Hospital Blunders

In the past months, there have been many reports of blunders at hospitals.  Some of these blunders were at best, embarrassing for the hospitals and at worst, fatal.  Today’s Standard reported that an investigation was carried out to understand why these blunders occurred.  I’ve highlighted the interesting (but tragic) bits in blue.

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`Military’ nurses behind blunders

A “military” culture among nurses – making quick work of their duties without thinking – is behind a series of “disheartening blunders” that have rocked pulic hospitals.

Mary Ann Benitez

Friday, September 04, 2009

A “military” culture among nurses – making quick work of their duties without thinking – is behind a series of “disheartening blunders” that have rocked pulic hospitals.

The Hospital Authority’s top nursing executive Sylvia Fung Yuk-kuen yesterday blamed errors by experienced registered nurses on critical lapses in attention and described them as mistakes waiting to happen.  She went through three recent high-profile cases and offered explanations in each.

A breast cancer patient who was injected with oral morphine because a nurse thought the syringe containing the solution was to be injected.

The patient died but not due to the morphine injection, preliminary investigations showed.

The nurse was not told that the syringe was being used to give the morphine orally because the woman was too weak to swallow the painkiller. “It was a trap, a mistake waiting to happen. We are looking at buying foolproof oral syringes,” she said.

Expired BCG vaccines injected into five newborns by a nurse was down to the “goodwill” of another staffer who wanted to save money. They kept the unused portion of the prepackaged multidose vaccine in the fridge instead of discarding it within four hours.

A second nurse did not check the preparation dates of the vaccine before immunizing the newborns two days later.

Two newborns whose identity bracelets were switched and whose mothers ended up breast- feeding the wrong babies for five days. Fung says nurses checked the names of the new arrivals on their cribs but not the bracelets.

She said the incidents are still being investigated and any disciplinary action will depend on the individual circumstances involved.

“Nursing training is like military training so nurses tend to be very obedient,” said Fung. She took over as chief manager (nursing)/chief nursing executive nine months ago and manages the 19,559-strong public hospital nursing workforce.

“Now we would like to encourage frontline nurses to voice their opinions on how to make practices safer or whether they are dangerous under the existing guidelines.”  Fung said an overall review of the “whole work processes” is being conducted to improve the administration of drugs to and how patients are identified and avoid future blunders.

The special nursing clinical review will identify the “critical control points” in a bid to reduce errors.

Hong Kong is also looking to adopt overseas nursing practices for administering drugs. These adhere to the “five rights” – right drug, right patient, right timing, right dose, and right method of delivery.

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