Patient received chemotherapy instead of antidepressants – Oppland Arbeiderblad

COUNTRY AROUND: [MOSS AVIS:] A patient who was discharged from hospital after a hip fracture Østfold received chemotherapy instead of antidepressants. The hospital broke the law, writes county medical Svein Rønsen in Østfold in an audit report.

The County Governor super- vision towards Østfold Hospital after the very serious incident. Now the investigation finished. County Governor concludes that Østfold Hospital has broken acceptability requirements of Specialized Health Services Act.

The case started when the patient fell on the floor at home and was admitted to hospital. Mistake occurred when the patient was to be printed from the hospital and transferred to Peer Gynt helsehus Moss for rehabilitation.

– Secretary of Documentation Center, who wrote discharge summary, had incorrectly perceived physician’s dictation on medication by the patient. Error The writing was not discovered when the doctor the same day he was called up to sign the memorandum before the patient was transferred, writes acting county medical Svein Rønsen and senior advisor Torgunn Bakken in the audit report.

Got antidote

discharge summaries were transferred electronically to the GP and was also sent in hard copy to the Peer Gynt helsehus. At the latter place, patients received the medicine as it stood on the discharge summary from the hospital that he should have.

– The patient was very poor. After three days of Peer Gynt helsehus the patient was transferred to the hospital again. The patient was so ill that he was hospitalized in intensive care. Eventually, the patient was referred to the internal medical evaluation. A specialist in blood diseases discovered incorrect medication. The patient was then antidote, the report said.

Sorry

The patient lived for a few months after the wrong medication, but is now dead. The manufacturer-independent drug information RELIS has documented several cases in Norway with a fatal outcome due to medication errors with this medication.

Østfold Hospital has undergone facts of the case and had conversation with the doctor, who was aware that he unfortunately overlooked error.

Østfold Hospital and Peer Gynt helsehus has now made proposals for improvement, to prevent something similar happening again. The proposed measures shall be submitted to the county governor.