Healthy Skepticism Library item: 278

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Publication type: news

Ridgen M.
CHR vows action on toxic mix-ups: Health region hires patient safety consultant
Calgary Sun 2004 Mar 24

Full text:

The Calgary Health Region is hiring a patient safety consultant from Winnipeg to make sure no one else dies from being given the wrong medication in hospital. The announcement was made yesterday after a fourth person came forward saying he was given potassium chloride in 2000 — two months after 59-year-old Patricia Evans nearly died from such a mix-up.

As a result of those incidents — both of which occurred at the Peter Lougheed Centre — the substance was removed from general wards in hospitals.

But that didn’t prevent the deaths of Kathleen Prowse, 83, and Bart Wassing, 53, in the past month at Foothills Hospital. The hospital pharmacy mistakenly put potassium chloride — instead of sodium chloride — in dialysis solution bags.

Three bags of the deadly solution were used on Wassing and two on Prowse. Thirty other bags in the botched-batch were taken out of the health system.

The health region’s supply of potassium chloride has now been moved to secured areas and they will purchase sodium chloride from a different vendor to prevent further mixups with similarly shaped bottles.

CHR chairman Da-vid Tuer said the board is bringing in Dr. Robert Robson, a patient safety consultant, to see what more can be done.

“His comprehensive review will look at the operation of our central pharmacy, examining how medications are prepared and distributed through the system,” Tuer said.

“I want to assure all Calgary Health Region residents that this report will be made public and that we will act on all recommendations.”

In the meantime, no action has been taken against those responsible for the fatal mix-ups.

Don Lemna, who was accidentally given potassium chloride following surgery in 2000, is outraged the substance can still being mistakenly administered four years later.

“I was infuriated when I heard that,” said Lemna.

He immediately felt like his body was on fire when he was wrongfully given the substance and, when a nurse realized the mistake, a response team rushed to his bedside and saved him.

He believes the CHR should have done more to prevent potassium poisonings. “I truly believe people died needlessly,” he said.