An Unfortunate Death and Avoidable Dangers

An Unfortunate Death and Avoidable Dangers

So there was this news recently about a young boy who died after he was mistakenly given diabetes and hypertension (sugar and BP) drugs by the pharmacist at a hospital. The case was taken to the court and the judge sentenced the hospital, the doctor and the pharmacist to pay a fine to the dead boy’s family.

Now I am not condoning what happened for one minute but i fail to see the logic of punishing the doctor. As a doctor i know that although we are ultimately responsible for the patient’s well being, we do have to trust others to be competent at their jobs too. We cannot be there at every single step of the way- supervising everyone else and at the same time seeing all our patients too. In my (maybe biased) view it was the pharmacist who bears the full responsible for he was careless in giving those drugs to the boy without checking what he was giving and to whom. That doctor had no way of knowing what had happened- he must have seen the patient, written the prescription and sent the boy on to the pharmacy. What happened later cannot be held to his account unless his hand writing was so bad that the pharmacist had mistaken the prescription and given the wrong drugs - which happens more often than you think.

Even on the off-chance that the pharmacist had a doubt on the prescription- the pharmacist should have called up the doctor immediately to ask about his doubt- he shouldn't have blindly given away the drugs. I mean, if the prescription is for a twelve year old how can you with any commonsense give him BP and sugar tablets? What I believe happened was the pharmacist must have been dealing two separate prescriptions at the same time and must have simply switched the two covers to different patients. The other person who got the children drugs must have simply not been cured while the child who got the adults drugs had died of overdose.

As sad as this episode is it reminds us that even the things we take for certain have the means to go wrong if someone down the line is careless for a minute. And that’s why I welcome the initiative to use computer/online prescriptions. The pharmacist can no longer explain any errors in giving drugs by blaming it on the doctor’s handwriting. and as for doctors part-I often use a simple fail proof method- instead of trusting blindly to the pharmacist for giving the right drugs- I ask the patient to come back to my cabin with the medicines so I can explain to them what to take and when to take. Of course I don’t do this routinely to all my patients (see them a second time that same day) - sometimes I just don’t have the time if an extra-large bunch of patients are crowding me- but most days I do use this final check. But I always, always use this for pediatric (child) cases - because I know that with children even the smallest error in dosage can have fatal consequences- so we need to take extra care when giving any medicine to kids.

The point of this post is – we know that medicines are life saving but they are also risky and dangerous if they are not the right medicines and are not taken in the right doses and in the right times. Always keep that simple fact in mind and check once, twice, thrice before taking medicines casually. And finally I just wish that other doctor had also called back that patient and checked his medicines. Or his mother had gone back to ask about them. If so the boy would still be alive today. Let’s hope this error never takes place again.