Woman died of legemiddelforgiftning – NRK Vestfold – Local … – NRK

the Woman died in 2014 of overdosage of the drug Methotrexate. The drug used in the treatment of several cancers, psoriasis and arthritis.

the Treatment was stopped for a period of the Hospital in Vestfold when she should be treated for another chronic illness.

After the treatment, she was discharged to the nursing home in Re where she lived. Sykehuslegen gave when oral information to the relatives that the treatment with Methotrexate should start again. The relatives gave the message on to the nursing home.

communication failure was fatal

A nurse at the nursing home called the doctor and asked if the woman should be put on the drug again.

Superior confirmed it. At the nursing home perceived that the treatment should be “10 mg x 1″. The woman was, according to the daily given dosage for one whole week. This happened over an unknown period of time. Finally, she managed not to take medicine.

She got abdominal pain, diarrhea, blistering in the mouth and sårinfeksjon. The woman was put into the Hospital in Vestfold again, and died after a short time.

the autopsy showed that the cause of death was benmargssvikt as a result of malpractice with the Methotrexate.

According to the State board of health claims superior that it was given the correct dosage on the telephone, but that it was written incorrectly in the note to the nursing home.

Re nursing home violated the requirement of proper treatment

company manager for health and care in Re municipality, Ingerd Saasen Backe, says the incident is very regrettable and that they should not take oral doseringer.

– We should have checked more closely, and eventually called the doctor up once more.

In the aftermath has the nursing home been closed down. Today has Re Helsehus sykehjemstjenestene in the municipality. E-messages and a new quality system is introduced. The nursing home also has additional focus on pharmaceutical supervision and employee training.

Refses of the State board of health

the State board of health struck in December 2016 fixed that the Hospital in Vestfold has broken forsvarlighetskravet in spesialisthelsetjenesteloven.

Broke the law

the State board of health came to the following after a the supervision of the then Re nursing home and the Hospital in Vestfold.

• Re nursing home (now closed down, sykehjemstjenestene coordinated on Re helsehus, journ.anm.) has violated the requirement of proper treatment in accordance with Health and omsorgstjenestelovens § 4-1 and Interkontrollforskriftens § 4. State board of health ba Re municipality health and care about the to use the incident in a learning perspective so that similar incidents do not happen again.
• In December 2016 found the State board of health that the Hospital in Vestfold has broken forsvarlighetskravet in spesialisthelsetjenesteloven § 2-2 cf. internkontrollforskriften section 4.

They conclude that it was improper that the outpatient ordination happened only verbally, and that the dosage of Methotrexate was not unequivocal.

In tilsynsavgjørelsen it states: “the State board of health considering that the Hospital in Vestfold has acted recklessly by not ensuring that the patient and/or the nursing home got the correct prescribing of Methotrexate, where the nursing home had the responsibility to take the medication”.

Measures the Hospital in Vestfold has introduced

• Sykehusapoteket mark all packaging with Methotrexat with the warning: Dosed 1 time a week. Daily use can result in serious poisoning.
• Methotrexat should have ukedagsangivelse.
• All personnel who have rights to legemiddelhåndtering get a separate hole cards for høyrisikolegemidler.
• the Hospital introduced in the autumn of 2015 electronic reseptforordning in reseptmodulen. It should prevent feilmedisinering. In the module, it comes up alert on the particular circumstances of each medication.
• It is laid out information about prescribing and kurveføring of Methotrexat on the hospital intranet.

Although the hospital has introduced measures in the aftermath of the event (see information below), believes that helsetilsynet that it is not sufficient to ensure that similar incidents do not happen again.

Boss at the medical clinic at the Hospital in Vestfold, Jon Anders Takvam, sorry it has happened. He says the doctors at the clinic after having received information that they should be aware of the dosage.

So have sykehusapoteket, in consultation with us, introduced a particular labeling of the forpakningene, which clarifies weekly dosage.

the Hospital has also distributed kunnskapssenterets information about the safe use of the drug, and taken up the matter in legemiddelkomiteén at the hospital.