Medical error - tip of the iceberg
In a rare admission of personal responsibility, a doctor has pleaded guilty to killing an 18-year-old cancer patient by mistakenly injecting a toxic cancer drug into the spine rather than a vein, according to an article published yesterday by BBC.
"Exactly the same mistake has been made in UK hospitals on 13 occasions over the last 15 years, with mostly fatal consequences", says the author of the article, but in reality we see only the tip of the iceberg.
According to this research (PDF document) by Ron Law in New Zealand, medical injury is not an exception but rather a major cause of death inside the hospital system.Cancer treatment with toxic drugs, today's universally accepted treatment mode, has been said to be based on politics rather than a desire to heal. There are numerous non toxic, effective alternatives to butchering patients but so far, suppression of these has been extremely successful.
I believe that the recent case where one of these "unfortunate events" was actually investigated and the responsibilities behind it brought to light is a precedent that should be imitated. We need transparency - not only in politics but also in medicine.
Doctor admits drug blunder killing
A doctor has admitted the manslaughter of a teenage cancer patient who died after a hospital drug blunder.
Wayne Jowett, 18, died after a toxic cancer drug was wrongly injected into his spine rather than a vein.
Dr Feda Mulhem, of Stanley Road, Leicester, pleaded guilty to the unlawful killing at Nottingham Crown Court on Monday.
Dr Mulhem had ordered a junior doctor to administer the drug into the spine - neither had been formally trained in giving chemotherapy.
An independent report later criticised staff and procedures at Nottingham's Queen's Medical Centre, and highlighted design faults in syringes and drug packaging.
Spinal treatment
The teenager was undergoing treatment for a form of leukaemia early in 2001 when the mistake happened - and was actually in remission from the disease.
The drug he was given to complete his treatment, vincristine, is safe if injected into a vein, but highly toxic if given "intrathecally" - into the spine.
Mulhem failed to note what was written on the patient's haematology chart and failed to see which drug should have been administered.
He also failed to check the route of administration and the syringe, which would have stated that the drug was vincristine and would have told him that the drug should have been injected into a vein.
The error only came to light when another junior doctor queried what had happened.
Bruce Houlder QC, prosecuting, told an earlier hearing: "What he did was to fail in a number of respects, which were absolutely basic in his responsibilities as a doctor.
"These failures led directly to the death of Wayne Jowett."
Although desperate attempts to reverse the treatment's effects were made once the mistake was realised, it was too late.
Wayne gradually became paralysed and died almost a month later when his breathing machine was turned off.
The two doctors were immediately suspended as Queen's Medical Centre set up an inquiry into the death.
The mistake happened because of a mix-up between two chemotherapy drugs which should never have been given to the patient at the same time.
The other drug, cytosine, was supposed to be given as a spinal injection.
Catalogue of errors
Exactly the same mistake has been made in UK hospitals on 13 occasions over the last 15 years, with mostly fatal consequences.
The Department of Health set up a committee - chaired by Chief Medical Officer Professor Liam Donaldson - to come up with ways of reducing the number of medical mistakes within the NHS.
Its report in June 2000 urged the government to examine ways of completely wiping out deaths and disability caused by "wrongly administered spinal injections" by the year 2001.
Work is being undertaken to reduce the risk of such events by designing vincristine phials so that they cannot physically be fitted to spinal injection kits.
Mulhem is due to be sentenced on Tuesday.
See also related articles:Why do pharmaceutical drugs injure and kill?
Pharmaceutical corporations accused
Why Death Rates Decrease When Doctors Go On Strike
posted by Sepp Hasslberger on Tuesday September 23 2003
updated on Tuesday December 11 2007URL of this article:
http://www.newmediaexplorer.org/sepp/2003/09/23/medical_error_tip_of_the_iceberg.htm
