The Age has been following the very sad story about a Victorian hospital causing severe brain damage in a baby through a simple mistake. The reports are here and here.
The one month baby was taken to hospital with persistent vomiting. Then:
...two days later he was diagnosed with pyloric stenosis — a condition that blocks the flow of food into the small intestine — and was booked in for surgery.
About 1am on September 19, consultant surgeon Paddy Dewan assessed the baby, conducted a tutorial on the condition for Dr Foo and recommended intravenous fluids to treat dehydration. At this point the boy's treatment went tragically wrong. Instead of a solution containing 5 per cent glucose, he was given a concentration of 50 per cent glucose, which led to his severe brain damage.
Ms Young told the board that Dr Foo, who had responsibility for prescribing and recording the fluids, maintains the solution was specified by Professor Dewan but another doctor present at the time rejects the claim.
Nurses caring for the baby raised concerns about the solution, which was described as unusual, but were reassured by Dr Foo that it was correct. Ms Young told the board that Dr Foo might not have understood their concerns.
In todays paper, it is reported that Professor Dewar:
...said he ordered a solution of 5 per cent dextrose, or glucose, which was to be made up using the hospital's supply of a 50 per cent concentrate.
An alleged transcription error by resident doctor Lea Lee Foo meant the baby was given a 50 per cent solution, causing massive brain damage. Dr Shobha Iyer and Dr David Tickell allegedly failed to check the fluids or adequately examine the baby later in the day.
Professor Dewan said it was unbelievable that the error was not picked up by any of the staff, and a culture where junior staff were not encouraged to question orders was partly to blame.
A few things to note here: the nursing staff questioned the solution, which I am guessing must be very unusual for a baby. (Your comments reader Geoff?) The parents tried to warn the doctors that the baby was getting worse, but the other doctors missed the problem with the solution too.
All very sad. For me, the lesson seems to be to question hospital staff a lot, to the point of being a real pest, if things seem to be going badly.
3 comments:
I agree, very sad. Most errors of this nature are caused by unsafe systems but this one has some worrying features. Inexperience plus fear can cause this and I well recall as a very young doctor unthinkingly doing exactly what I was told by a superior to do and then being in trouble because it was not safe. More worrying here is a lack of basic science. There have been reports that young doctors have less background in basic science because of the way the courses have changed in becoming postgraduate - such a high concentration should be known not to make sense from an osmotic perspective.
Geoff
Geoff, would a doctor ever use the 50% solution, on a baby or an adult? I guess they must, or surely the nurses would have known it wasn't just "unusual". Is it just made that way so you can always dilute it to the strength needed?
You'd use it for very severely low blood sugar. Because of the high concentration it is an osmotic diuretic and it is going to suck fluid out of compartments like the brain so it can also be used to rapidly lower the pressure in cerebrospinal fluid.
Its product information state that except in emergency it is to be diluted. The story doesn't add up - glucose comes in 5% vials in any case. Also if it was for dehydration you'd expect just a normal drip to be put up. I wonder if the tutorial strayed into a talk on the uses of glucose and the doctor got confused between the orders for the baby and some example being discussed by the surgeon.
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