The recent case of medical malpractice has put civic run KEM hospital, Mumbai in the spot light again. The BMC run hospital has initiated an inquiry into the alleged case of negligence in which a 34-year-old woman died on Thursday. The woman had been admitted with high fever and bleeding after childbirth and to the gynaecological ward of the hospital.
The woman went into respiratory failure and later multi organ failure after a nurse administered a Feracrylum injection (a clotting agent) instead of a paracetamol injection. The nurse realised her mistake after a few hours and immediately alerted the attending doctor, who found it difficult to reverse the woman’s condition. The initial scans of the woman’s internal organs showed that blood clots had formed internally and were causing her organs to fail.
Feracrylum is a polymer and is hygroscopic (soaks water from the atmosphere) in nature, soluble in water, non-absorbable in the system. It forms complexes when it comes in contact with blood, and thus causes blood to clot. The clot has a gel like structure, which creates a physical barrier when oozing (due to bleeding) occurs. This unique property also prevents bacterial growth on and near the wound site. It is commonly used in dental procedures. One of the most important contraindications in this drug has is that it should never be used intravenously. It is a topical agent (applied on the skin or outer layer of the body) and can have devastating effects inside the body.
How could such an error occur?
In a civic run hospital the ratio of nurses to patients is often 1:15 or more. This means that there is only 1 nurse for about 15 or more patients. The nurses are often over worked and underpaid, and although they are taught to be alert while administering a drug, lapses occur with lowering physical strength.
In this case when the nurse had been instructed to administer a Paracetamol injection, she likely would have filled two syringes, simultaneously for two patients, not realising that syringes were not marked. The syringes could have been mixed up. Another possibility is where the nurse must have picked the wrong bottle, as they are normally placed next to each other, distractions could have led to this error.
Administrative action:
Medical negligence with an accompanied police complaint is usually termed as a medico-legal case, where the case is transferred to the concerned department in the hospital who co-ordinate with the police to provide them with evidence needed. In this case no case has been filed by the patient’s family. The police have filed a case of accidental death and are waiting for the post-mortem reports. The reports will give the police a better picture of what really happened on that day and accordingly the action taken and charges filed will be changed.