A patient who died last summer from a chemotherapy overdose at Haukeland University Hospital did not receive adequate healthcare, the county administrator said.
Following an investigation into the death, the State Administrator of Western Norway concludes that the cause of the incident is complex. Mention is made of individual errors both in the oncology department and in the hospital pharmacy, but responsibility largely rests with the management of the companies involved.
According to the State Administrator, there is a rounding error in the electronic chemotherapy delivery system. Thus, a dose was administered ten times too high.
The pharmacists who made the final inspection at the pharmacy did not react, writes the State Administrator, and the dose was delivered to the oncology clinic. It was only after the patients had received about 80 percent of the dose that the error was detected by chance.
The oncology department and hospital pharmacy in Haukeland independently analyzed the incident and implemented appropriate measures. The case was also investigated by the police.
Here are some examples of consecutive deaths caused by personnel error.
Since 2014, Norwegian hospitals have made at least 20 mistakes that could have been prevented with treatments that were already used. The examples unfortunately show that for many patients the result was fatal.
The twins die in the womb
2015. Innlandet Hospital. Twins die in the womb. The team they had was not detected. The study was recommended.
The patient dies after starvation
2017. Nordland Hospital. The patient dies due to lack of food. The serious condition may have been detected with a tool used by other departments. The patient's clinical status tool, used in other departments of the hospital, could possibly have revealed worsening earlier and prevented death.
Patient who underwent spine surgery has cardiac arrest
2017. Haukeland University Hospital. A patient who has undergone spinal surgery has cardiac arrest after inappropriate treatment. The cardiac arrest was caused by an overdose of painkillers, but the patient recovered from the incident without permanent injury.
The nurse has poor hearing - a woman with cancer dies
2018. St. Hospital Olaf. Woman suffering from cancer needs calcium chloride. The nurse misses the "s" and instead administers potassium chloride to the patient. The woman dies.
20 cases - 14 deaths
These are just a handful of the 20 special cases of medical malpractice in Norwegian hospitals in recent years.
Common to 20 cases is that hospitals themselves admit that the errors could have been prevented.
