Ste-Justine fixes protocol on injections after deaths
Officials at Ste-Justine Hospital pledged on Monday that they’ve upgraded their safety protocols after a baby and a toddler died within weeks of each other in 2016 following medication errors involving injections of potassium.
In the first case, a two-and-a-halfmonth old girl suffering from dehydration died on Nov. 18, 2016, after a nurse mistakenly injected her with a dose of potassium chloride that was 10 times greater than what was prescribed, coroner and physician Jacques Ramsay concluded in a report released Monday.
The excessive dose caused the girl to plunge into a cardiac arrest and to be wracked with convulsions from which she never recovered. In the second case, a 23-month-old cancer patient being treated for neuroblastoma at the Côte-des-Neiges hospital died on Dec. 10 that same year after a nurse accidentally administered an injection of potassium rather than saline to the boy.
Hours after the coroner made public the two reports, Ste-Justine — Quebec’s largest pediatric hospital — released a statement expressing its condolences to the families, and emphasized that it has since adopted strict protocols to prevent similar medication errors from recurring.
“We’re very saddened by these events not only with regard to the families but also with regard to the (medical) teams that were involved,” Dr. Marc Girard, SteJustine’s director of professional services, told the Montreal Gazette on Monday.
Girard declined to say whether the nurses who made the errors have been disciplined, but he did note that staff “have been met with individually and collectively and we’ve followed up with them.”
Under the new protocols, a prescription of potassium will have to be verified in writing by both a pharmacist and a nurse before it’s injected into a patient.
“As you know, when we administer a medication there are several steps,” Girard explained. “It starts with the prescription, then the preparation and finally the administration of the medication. At each of those steps, we’ve increased our control processes.
“The (prescriptions) have to be checked by two professionals, a pharmacist and a nurse,” he added. “Since then, we have not had any incidents.”
Protocols have also been strengthened for other medications at Ste-Justine. What’s more, the hospital delivered a video conference on medication safety last month to health professionals across the province.
The coroner observed that Kaylynn Mianscum-Kelly, born on Aug. 27, 2016, was scheduled to undergo heart surgery at Ste-Justine in late November when she started to vomit and suffer from diarrhea on the evening of Nov. 17.
A medical resident decided to rehydrate Kaylynn with an intravenous solution containing sterilized water with some sugar, salt and potassium.
However, out of habit, the nurse used an IV device, Buretrol, and miscalculated the dosage of potassium by 10 times.
In the second case, Ghali Chorfi was being treated for metastatic neuroblastoma, which had attacked one of his kidneys, that had been responding to treatment. On Dec. 10, 2016, the boy was given medication as part of that treatment and, after that was finished, he was supposed to receive a routine injection of saline to rinse out his vein.
The child reacted almost immediately to the potassium injection, his pulse stopping and his limbs flailing as he went into cardiac arrest.
The nurse and other staff began resuscitation procedures on the boy, and a blood test conducted 15 minutes after the injection found dangerously high levels of potassium in his system.
While medical personnel eventually succeeded in reducing the presence of potassium, the cardiac arrest and the effects of the resuscitation procedures took their toll and the child died that day.
The coroner concluded that the child had been inadvertently injected with potassium rather than saline, causing him to go into cardiac arrest.
Ramsay made it clear in his report that there is no evidence the death was the result of anything other than an accident.
In his recommendations, Ramsay noted that Ste-Justine Hospital had already undertaken measures to ensure such incidents are not repeated.
But at the same time, he drew attention to the fact that the Institute for Safe Medication Practices in Toronto had published stringent guidelines on the use of potassium in 2006.
The (prescriptions) have to be checked by two professionals, a pharmacist and a nurse. Since then, we have not had any incidents.