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Inexperienced SGH nurse allowed to operate pump machine, may have caused death of elderly patient

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Madam Chow, 86 years old and admitted at the Singapore General Hospital (SGH) was accidentally given 10 times the anesthetic prescribed, a dose which was assumed to be 10 times the actual dose.

Wednesday (Dec 19), an investigation into the demise of Madam Chow Fong Heng, revealed that she was expected to be treated with 4.17ml of intravenous lignocaine every hour. However, the staff nurse assigned to her erroneously entered “41.7” into the IV Smart Pump in introducing lignocaine to Madam Chow’s system.

The coroner (Marvin Bay) however clarified that the overdose was not the direct contributor of the patient’s death but a series of ailments including hypertension and end-stage renal disease and that she actually died of a natural cause. Nonetheless, the coroner did admit that there is need for concern on the matter. According to Bay, SGH accepted their inadequacies in the instruction, guidance, and appraisal of its nurses’ proficiency.

Coroner Bay was quoted as saying, “In the event of severe overdosages of lignocaine, the affected patient could develop seizures and central nervous system depression. A severe overdose can contribute to morbidity and mortality.” Yet, Madam Chow, who died June 2, 2016, never exhibited seizures expected with a lignocaine overdose. A forensic pathologist found that she died of multi-organ failure and septicaemia (blood poisoning).

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Replying to inquiries, SGH’s chief of nursing, Dr Tracy Carol Ayre, said the hospital feel sorry for the incident and assured everyone that appropriate action has been taken against the staff involved.

Dr. Ayre added confided that there have been significant lessons learned from the incident saying, “We have taken further steps to strengthen our processes in the administration of medication. In the training and assessment of our nurses, steps have been taken to reinforce strict compliance with counter checking when administering unfamiliar medication… System alerts have also been put in place to prompt when there is any discrepancy noted. Staff members are to call for help when they encounter pump alert and discrepancy.”

The lessons drawn from the terrible accident have been shared with all of SGH’s nurses, the doctor concluded.

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