Medication mix-up leaves cancer patient, wife shocked
Man given different patient’s medications by mistake at Health Sciences Centre
A Winnipeg man who underwent cancer surgery at the Health Sciences Centre says he feels lucky to be alive after hospital staff gave him medication that was intended for another patient in the next bed.
In an interview with CBC, Karl Kollinger and his wife, Marlene Kollinger, said the medication error is one of several mistakes they discovered during his recovery from March 18 cancer surgery.
“We are very fortunate that Karl is sitting here today. The outcome could have been grave, and he could have been dead,” Marlene said.
“I can't answer for myself when I'm sedated," said 72-year-old Karl. "Something could have happened.”
2,000 medication errors at HSC in 2 years
Kollinger became one of the 2,000 people to experience a reported medication error at the Health Sciences Centre in the last two years.
He and Marlene said before the surgery, it had never occurred to them Karl might be given the wrong drug, even though medication errors are not uncommon.
They said they were preoccupied by Karl’s health and whether he would make it through the operation without hemorrhaging.
“I was diagnosed with colon cancer and prostate cancer and bone cancer, all before Christmas,” Karl said. Karl would also suffer a heart attack shortly after that.
Wrong IV bag
Two days after the cancer operation, Marlene was with Karl in the hospital room when she noticed her husband’s intravenous drip medication did not have his name on the bag.
It had the name of another patient on it.
There’s probably more occurrences that aren’t being reported, and we can't let the ball drop. We've got to keep pushing on the reporting,- WRHA Chief Medical Officer Brock Wright
Marlene said she went out into the hall and called the nurse.
“And I got kind of upset, and I said to her ‘How can this happen? Did you not check his bracelet?’ At this point, Karl put his hands up from underneath the blanket and said ‘I’ve got no bracelet,’” Marlene said, referring to the identification wristbands patients are supposed to be issued when they’re admitted.
“I said ‘How could you not have a bracelet? How have they been administering — for two days — drugs to you without checking who you are?’” said Marlene.
“At that point I was extremely upset, went out and demanded to see a doctor,” she said. “At this point they tried to remove the IV bag, and I was adamant, ‘You don't touch anything until our surgeon comes.’”
Notes in Karl’s medical chart indicate the nurse acknowledged she had given the wrong medication and apologized.
The medicine in Karl’s IV drip was an antibiotic that was supposed to be administered to the other patient in his shared hospital room.
Karl was supposed to receive a drug called pantoprazole – which controls the amount of acid the stomach produces -- while he recovers from removal of a large tumour and a section of his bowel.
Marlene said the surgeon has not made Karl aware of any apparent harm from the mix-up.
But when medication mistakes happen, the outcome can be serious.
14 critical incidents
Winnipeg Regional Health Authority data show that during a three-year period, there were 14 critical incidents related to medication reported at the Health Sciences Centre.
Ten of those patients suffered major injury, and two of them died.
“To err is human but in a case like this, this was not so much an error as a complacent nurse who was not paying attention to what she was doing and that is very, very dangerous,” Marlene said.
Without commenting specifically on the Kollinger case, WRHA Chief Medical Officer Brock Wright acknowledged patients should be wearing an identification bracelet.
Punitive approach not the answer, says WRHA
While Karl said he thinks someone should be disciplined over his medication error, Wright said a punitive approach is not the answer.
Wright said the WRHA wants to encourage staff to report errors when they happen so that everyone can learn from them.
“There’s probably more occurrences that aren’t being reported, and we can't let the ball drop. We've got to keep pushing on the reporting,” he said. “So a region or a hospital that has a large number of incidents -- it would be wrong to assume they're doing worse than somebody who has a much lower level.”
He said the approach has changed a lot since the system he observed in the 1990s when a staff person might have been suspended without pay for errors in care.
“We know that the vast majority of errors that are made are made by hard working, well-intentioned health care providers who are often very busy and doing the best they can,” Wright said. “I’d like to believe that a number of things that we have been able to do over the last several years have made the system safer. But to be honest, I think, as good as we are at reporting, relative to other jurisdictions, I think we could be better.”
Majority don’t harm patients, WRHA says
He added the vast majority of the 2,000 medication occurrences reported at the HSC since 2012 did not involve harm to the patient.
The lack of ID bracelet and the medication mix-up were not the only things that went wrong in Kollinger’s case.
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Kollinger was supposed to avoid eating and drinking after surgery. Instead, hospital staff brought him a full tray of lunch, Marlene said.
“They were adamant that it was my husband’s. It’s a good thing that he was very sedated with morphine, otherwise he would’ve been tempted to eat it,” she said. “I looked at the tag [on the tray] and it belonged to the gentleman in the next room.”
Marlene said she can’t understand why an ID wristband wasn’t put on Karl when he was admitted to hospital.
“Anyone that's gone into a hospital knows the first thing they do is put an ID bracelet on. They check. They even ask you your birth date. That is their way of monitoring a safety factor,” she said.
The nursing notes in Kollinger’s chart indicate even though the patient wasn’t wearing a wristband, the nurse had asked Kollinger his name that morning.
Kollinger said he couldn’t follow everything that happened because he had been under sedation.
“It was a good thing that Marlene was there because I was in la-la land, you know,” said Karl.