Coroner satisfied with new injection safety measures hospital has introduced

The death of a diabetic man eight days after he was injected with undiluted medication was accidental, a coroner ruled yesterday.

An autopsy confirmed that Cheung Sup, 89, died of bronchopneumonia, pulmonary oedema and cardiac arrest.

The underlying cause of death was the accidental injection of undiluted potassium chloride, which led to cardiac arrest.

'The hospital's guidelines require two nurses to work together to follow the 'three checks, five rights' system in the injection procedure,' Coroner Paul Kelly said.

'The last 'right' was not ensured - which says administration of the drug be on the right route . . . but only one nurse, [of] junior [rank], was by [Mr Cheung's] bedside,' he said.

The 'three checks' concern the medicine. Nurses are required to check the container holding the medication before and after the injection and before disposal of the container.

The 'five rights' to ensure a correct injection are: right timing, right prescription, right patient identity, right dosage and right route (the way the medication is administered).