Source

I've gone through two departments in Medicine and Surgery and 3 times I did things that were ignorant and someone could have paid...in fact one was deadly and in one case someone died.

Yes, I said it...a patient died not because of my mistake but I didn't report a mistake and that was the issue. But let's go through them in sequential order.

The first time

I was in Pediatric surgery and for the purpose of this story (not for an excuse), I was very very tired and had a long day of work.

We had 12 new patients...we did 3 surgeries that day and I struggled to give Afternoon medication and when evening came I was assisting a surgery that lasted from the evening till around 3 am.

After the surgery, I went to the wards to give evening drugs by 3 am. I was tired but I managed to scale through probably finished around 4 am

I went to my room and slept for 3 hours, brushed my teeth, and tried to stabilize my drug routine by giving the drugs by 6 am.

Some of the patients' lines had formed tissues blocking them so we had to set new ones.

When I was done, I was feeling really competent and a patient's mom asked me to help give drugs to her child.

I had been friendly with the mother so she needed help, I thought nothing of helping her and that's when I messed things up.

The patient was a multiple trauma patients being managed by many units.

Source

She was just getting better and responding to treatments when I stepped in and mistook a Diazepam bottle with Paracetamol. They didn't have the labeling like the one you see in that picture. There was no write up just a blank bottle.

She was probably on that drug because of the seizures she had been having a while back.

After I gave the drug She started hallucinating and saying incoherent things to her mother. Her mother cried out for the attention of any personnel.

When the nurse showed me the patient I had given paracetamol to, I felt like pulling my hair out.

I immediately asked for help from a senior and he came and started running Normal saline. She slept off and later she started feeling better.

I left work early that day and I refused to give drugs that day...I chose to rest cause I needed it.

Days later, my body shut down and I fell sick for weeks.

The second time

I had been giving chemotherapy to a patient and everything had been going well. I handed over the process to the next House officer and told him to give the antiemetic medication (To prevent vomiting) after 8 hours of the last one.

When I came in the morning the patient's father raised some concerns about the drug Ondansetron that was given over the night.

He described the amount the child got 1 and half a bottle and the child was to get two-third of a bottle. I understood why that mistake was made.

The bottle reads 2 mg of Ondansetron in every ml and it is a 4 ml bottle. So for someone who had not read the bottle properly like the other House officer, a mistake could be easily made.

The child had been vomiting and the father was bothered that the drug might be the cause of the vomiting. I was sure the vomiting was not caused by Ondansetron overdose but the temperature of the child was something I could not be so sure of.

I check quickly and found that the drug only causes blurry vision.

By the next morning, the child had died and the father was pointing fingers at both of us. I was included because I covered up the other House officer's faults.

It felt terrible to have someone die after that mistake.

I couldn't blame the father for not wanting to see my face and he was right, a senior should have known about it and I was responsible. I should have reported the situation to a person of higher authority and not been quiet about it.

The last time

This was about 2 weeks ago and I was aware I would be writing this post when it happened and I didn't want to have an extra story to tell people.

What happened was I was being super busy that day because of the massive flood of patients we were receiving. It was 5 new patients that evening all of them required urgent attention and all of them we had admitted earlier were either dying or screaming out for help.

A patient had been convulsing for some minutes and I felt it would be right to stop the seizures. I instructed the nurse to give Intramuscular Paraldehyde and she was being slow about it. I understood she had a lot of work on her hands so I went and gave it through the intravenous route.

That was when the patient began to gasp for air. The patient was already on intranasal oxygen and one of the side effects of paraldehyde is poor oxygenation.

I reported it to my senior immediately and she took me outside the emergency and whispered "You don't give Paraldehyde IV or at least without dissolving it first".

She told me I should do nothing, the patient will be fine. I couldn't help but check all the side effects of the drug all through my doing nothing and patients needed me at that time.

Conclusion

I don't know what the conclusion is. I think doctors can make mistakes cause we are human.

If we want better health care then as a country we need to employ more labor.

As a doctor, you need to confirm everything twice or three times even cause someone could die from your mistakes.

REFERENCES

• Virchow's Triad
• Myhealth Alberta
• Wiki Ondansetron