MEDICAL NEGLIGENCE PATIENT SAFETY 1.8A
Medication Mistake
John Whelan with Specialist expertise in Medical Negligence and Patient Safety gives an example of a case which falls outside of the definition of a Notifiable Incident as envisaged by item 1.8 of the Patient Safety Act 2023. This example involves similar mistakes to that envisaged by item 1.8 of the Act but yet since it doesn’t lead to the death of the Patient it is not a Notifiable Incident as defined by Item 1.8. This example is one of many cases which should fall within the ambit of the Patient Safety Act and can be introduced by a Ministerial regulation under Section 8.
Item 1.8A
A notifiable medical incident involving a medication mistake refers to a mistake in prescribing dispensing or administering medication that results in harm to the Patient.
An example would be incorrect drug administered.
A Patient with a history of chronic kidney disease is admitted to hospital for an infection. The doctor prescribed one antibiotic to treat the infection, taking into consideration the Patients renal function.
However, due to a mix up in the pharmacy, the Patient is mistakenly given another antibiotic, a different antibiotic that can be toxic to Patient’s with an impaired kidney function at higher doses.
Due to the Patients compromised Kidney function, the incorrect medication led to nephrotoxicity, worsening the Patient’s renal impairment. The Patient begins to experience a decline in Kidney function resulting in the need for temporary dialysis and prolonged hospitalisation.
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