Drug Allergy
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a destitute died after a nurse gave him a drug that he was allergic to.
she was found guilty of negligent but the coroner praised her.
she was the only nurse, having to take care of 180 patients.
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take more workload, make mistakes, boss praises u
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yeap
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i fail to understand why there was only one nurse?
she has since left her job. -
DING
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Strange... why was the nurse allowed to give medication without the doctor's orders?
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If she didn't have orders, do you think she'll be giving any in the first place?Originally posted by cornyfish2000:Strange... why was the nurse allowed to give medication without the doctor's orders? -
Well, haven't heard of any doctor being hauled to court over this case..Originally posted by ditzy:If she didn't have orders, do you think she'll be giving any in the first place? -
the nurse knew his allergy. thats why she was adjudged to be negligent. all the doctors were cleared in this case.
in her affadavit she acknowledged her oversight. -
It's a misfortune but what done have been done. It's isn't easy for a nurse to take care of more than 10 able-bodied patiences, yet she managed 180 aged patiences. Maybe we shouldn't criticise anymore since she've already admitted her mistake and had since left her job.
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i dont think anyone blames her for it.
but why only one nurse? -
How many nurses you know want to work in a home for destitute people?Originally posted by dragg:i dont think anyone blames her for it.
but why only one nurse? -
at least not one for 180.Originally posted by ditzy:How many nurses you know want to work in a home for destitute people? -
poor old folks. now there's no missy to look after them.
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what was her punishment leh?
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if she is the only nurse and she had left that place... who's caring for the destitutes now?
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no punishment, i guess it was because of the extenuating circumstances.Originally posted by kendoboi:what was her punishment leh?
i think it is a fair. -
wtf... she should still be given a chance...
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extracted from stforum.
Health care system must stop blaming individuals. Set up fail-safe methods instead
I refer to the report 'Nurse found negligent but coroner praises her' (ST January 1
. It is most commendable for the State Coroner, Mr Tan Boon Heng, to give due recognition to the challenging circumstances under which the nurse, Mdm Grace Leong, had to care for 180 patients singlehandedly in the Tembusu Home.
Learn lesson from sad story of drug allergy death. Give those who erred a chance.
However, it is most unfortunate that Mdm Leong was found negligent when in fact the error that she made was non-intentional and a completely human one.
What can we expect of a nurse called to perform super human duty? It is very sad that there is no recognition of the selfless and professional caring given by Mdm Leong to the residents as evidenced by the comments from the daughter of the deceased, that the latter 'was asthmatic and had health problems due to his long stint of drinking... but he was doing fine there.'
I also fail to understand the rationale to strike Mdm Leong off the roll as a nurse when Ms Susie Kong, executive director of the Singapore Nurses Association, had stated, 'How can you expect a nurse who has to take care of all 180 residents to also provide the standard of care that is expected to be given to sick patients?'
Furthermore, should not the responsibility of the error be shared by the hospital that had made the diagnosis of allergy? Why was not the patient registered with Medik Awas and given a bracelet to be worn at all times?
An article in the Singapore Medical Journal in 2002 has recommended that a systems approach be adopted towards improving patient safety. To quote: 'The systems approach makes the fundamental assumption that health care related or medical errors are, with rare exception, not caused by incompetent or uncaring physicians, nurses or pharmacists. People make mistakes no matter how hard they try.
"Analyses of errors clearly reveal that underlying vulnerabilities in the system are the primary problem. This means that the health care system must cease blaming individuals and design checks and balances ('fail-safes') into care and delivery processes to catch and correct errors before a patient is harmed.'
It has also been noted that 'we have an intense blame culture to grapple with, and this constitutes the greatest hurdle in developing our hospitals into high reliability organisations.'
We need to become a more humane society and to learn not to judge others without first coming to terms with our own human weaknesses and failings. It is a sad day for our nation when a caring nurse is penalised for making a purely human mistake in performing a superhuman duty!
Dr Patrick Kee Chin Wah -
extracted from stforum.
Learn lesson from sad story of drug allergy death. Give those who erred a chance
I refer to the report 'Drug allergy death, nurse found negligent but coroner praises her' (ST Jan 1. I read with sadness the death of Mr Mohamad Zain Abdul Aziz. I'm also sad that a dedicated nurse will likely be struck off the register and never serve her patients again.
Although I do not know nurse Grace Leong personally, I have known many healthcare workers who have given their utmost in the face of daunting challenges similar to the conditions faced by Mdm Leong's.
Mistakes must be expected in any circumstances. One of the quality programmes that many organisations aspire to attain is Six Sigma, which translates to 3.4 defects per million opportunities.
A nurse in her lifetime may process as many as one million prescriptions. With such a large number, mistakes will surely be made as we are human.
Whether such errors result in severe outcomes such as death is a matter of chance. It was unfortunate that Mdm Leong's error resulted in Mr Zain's death and caused anguish to his family.
The United States Institute of Medicine report in 1999, 'To Err is Human', found that errors in healthcare practice are common. Although such figures may appear worrying, instead of placing the blame on individuals, we should analyse the root cause that results in such errors.
The solution is to eliminate or change processes that increase the likelihood for failure. In this case, the root cause may be having an unrealistic nurse-to-patient ratio or other reasons.
Placing the blame on an individual does not acknowledge the failings of the system and will not ensure that the next person on the job will not make the same mistake again.
It will also result in the reflex action of individuals hiding or covering up their mistakes whenever possible. On the contrary, those who make genuine mistakes should be educated to become more effective workers in future. This does not mean that those who are wilfully or criminally negligent should go unpunished. In our enlightened society, we should strive to increase quality through system and process improvement and with constant monitoring and feedback.
Only through the increased reporting of errors and process improvement will we be able to minimise errors and ensure that deaths such as Mr Zain's will be a rare occurrence indeed.
I believe that those who have erred but are given another chance will be more aware of these processes and can continue to contribute to our society. After all, how many of us have never made a mistake that may have resulted in severe damage?
Dr Vernon Lee Jian Ming -
extracted from stforum.
Nurse with 180 patients: System needs fixing too
I WAS shocked to read that a single nurse could be made to look after 180 patients, especially in a First World nation such as Singapore ('Nurse found negligent but coroner praises her'; ST, Jan 1.
It is hard to imagine how any human being - however competent or diligent - could provide the expected standard of care.
To put the issue in perspective, school students are generally healthier than elderly inmates, yet no school would leave just one teacher in charge of the welfare and safety of 180 students.
While the coroner may have found negligence in the administration of a drug which the patient was allergic to, it is harsh that nurse Grace Leong now faces the prospect of being struck off, while the welfare home has presumably escaped sanction and will continue to operate.
It is true that nurses - while human and thus fallible - owe a duty of care to their patients. Yet care is not provided by individuals alone, but by organisations and the systems set up therein.
When accidents occur, it is crucial to look not just at the individuals involved in making the error but also the system and organisation which permitted such errors to happen.
If there was negligence, we should also look at how a system was set up which placed Madam Leong under such inhuman working conditions.
When workers are overloaded and stretched to the point of exhaustion, the shocking thing is not that such errors occurred - it is that such errors did not occur with greater frequency.
Tan Wu Meng -
My email to stforum:
The recent incident at Tembusu Home has highlighted the kind of overloaded working conditions some nurses are in. How could such nurse patient ratio be acceptable in a modern country like Singapore? Does Singapore Nurses Association or Ministry of Health have a minimal ratio which hospitals or healthcare institutions need to maintain? There is a good reason behind such quotas on staffing to maintain a balance between patient's need/safety and the institution's budget taking into account the current nursing manpower situation.
While this incident has singled out the nurse for being negligent and as a result she may loose her license but it does not solve the problem. Such incidents will happen again and again if nothing is done to enforce the minimal ratio if not at the same home or another healthcare institution.
Do nurses have a channel to voice out when they are put to such unfair working conditions? Can Singapore Nurses Association come in to protect its nurses from such employers? -
Recommended ratio for an acute hospital in the US:
Extracted from http://orbstandard.com/JMungai/?p=2
In the 10/22/02 press release, “Penn Research Finds More Patients Die In Hospitals with Lower Nurse Staffing” it states, “If all hospitals in the nation staffed at 8 patients per nurse rather than four, the risk of hospital deaths would increase by 31 percent, roughly translating to as many as 20,000 avoidable deaths in the U.S. annually. In other words, “Adding two patients to a nurse already caring for four, increases the risk of death by 14 percent, adding four increases the risk by 31 percent.”