Elderly Woman Accidentally Given 10 Times The GHS Prescribed Dose


SINGAPORE: An elderly woman accidentally received 10 times her prescribed anesthetic dose while undergoing treatment for various ailments at Singapore General Hospital (SGH) two years ago, a coroner’s inquest found on Wednesday ( December 19).

Ms. Chow Fong Heng was pronounced dead two days later in a GHS department, but a medical examiner certified that the cause of her death was multiple organ failure and blood poisoning, with end-stage kidney disease as a contributing factor.

Serious overdoses of the anesthetic called lignocaine can lead to seizures, morbidity and mortality, said a doctor at SGH’s National Heart Center.

Mdm Chow did not show any signs of seizures expected from an overdose of lignocaine.

Dr Ong Hui Shan, who examined the health condition of the 86-year-old man on May 31 after the discovery of the medical error, found that Mdm Chow’s mental condition had deteriorated.

However, she told the inquest that she could not attribute the toxicity of lignocaine to any role in Mdm Chow’s death, as Mdm Chow “had suffered from life-threatening illnesses, including sepsis, kidney failure and severe illness. ischemic heart disease “.


A GHS nurse who set up the pump that was to deliver the drug to the patient over a period of time accidentally entered a figure of 41.7ml / hr instead of 4.17ml / hr, Coroner Marvin Bay said at the time. that he was giving his conclusions on the death of Mdm Chow.

In May 2016, Dr Chow was prescribed 1 g of intravenous lignocaine – used to numb tissue and treat a rapid heart rate – for 24 hours. However, he was infused for 2.4 hours instead, the coroner said.

The nurse who typed in the wrong numbers was not identified in court documents. She said she could input dose selection or rate selection into the smart IV pump used to inject lignocaine into Mdm Chow.

For the calculations to be correct, she should have entered 41.7 mg per hour using the dose selection or 4.17 ml per hour using the rate selection.

However, she accidentally entered 41.7ml in the rate selection, she said, adding that she was unfamiliar with the smart pump due to her limited exposure to it.

The staff nurse said she took care of another patient after entering the number and continued with her routine duties afterward, conceding that she had not checked with a colleague if the parameters had been entered correctly.

In his conclusion, the coroner said two expert reports from the Singapore Academy of Medicine indicated that lignocaine was unlikely to be a determining factor in the death of Mdm Chow.

Despite this, the coroner said there were valid concerns in this case.

The staff nurse said “she had no experience and limited exposure to the pump machine, but was allowed to operate it nonetheless,” he said.

“She had of course made a gross error in the calculations regarding the amount of lignocaine administered, apparently confusing the application of milligram and milliliter units and confusing the dose selection with the rate selection in the calculations of the concentration of the drug. medication, giving Mdm Chow a dose that was effectively 10 times the prescribed dose, ”the coroner said.

He noted that SGH has recognized its shortcomings, taking steps to reinforce the importance of cross-checking where drugs and sedatives are administered.

He also ensured that nurses had “the skills and knowledge required when tasked with administering medication to patients,” he added.


SGH said on Wednesday that the hospital had taken “appropriate action” against the employee involved in the incident.

“We are sorry for the death of Mdm Chow and regret the incident even though it did not directly contribute to her death,” Dr Tracy Carol Ayre, chief nursing officer at SGH, told Channel NewsAsia.

She said the hospital had learned important lessons from the incident and taken steps to strengthen its drug delivery processes.

Steps have also been taken in the training and assessment of its nurses to strengthen strict adherence to crosschecking when administering unknown drugs, Dr Ayre said.

SGH requires that all registered nurses undergo annual competency assessments and regular training to ensure that they are sufficiently equipped to administer medications safely.

System alerts have also been put in place to notify nurses when an abnormality is found, and staff should call for help when they encounter an alert and a pump abnormality, Dr Ayre said.

“We place the highest priority on patient safety and take it seriously,” added Dr Ayre.

“We have also shared the lessons learned with all of our nurses, as part of our ongoing efforts to achieve zero harm to our patients. Appropriate action has been taken against affected staff.”

SGH did not say what the “appropriate measure” was, but said the employee was still in the hospital.

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