Elderly woman with respiratory disease accidentally given psychiatric medication in Hong Kong hospital blunder
Staff at Alice Ho Miu Ling Nethersole Hospital in Tai Po only discovered the mistake two months later
A hospital dispenser who wrongly gave psychiatric medication to a patient with respiratory disease failed to report the mistake and management only found out two months later on a staff discussion forum.
The 75-year-old woman was given the drug, a mood stabiliser, while visiting the accident and emergency ward at Alice Ho Miu Ling Nethersole Hospital in Tai Po on October 22 with a respiratory tract infection.
She felt sleepy but did not develop any signs of discomfort. The dispenser discovered the mistake 90 minutes later and contacted the patient and her family. The patient’s vital signs were stable but she was admitted to a medical ward for two days of observation.
It’s like hitting someone with a car but leaving the scene without taking responsibility, which is a more serious crime
Hospital managers were unaware of the mistake until they saw discussions about it on the intranet staff platform in late December. Immediate follow-up action was taken and the blunder was reported to the Hospital Authority on January 4. An investigation report will be submitted to the authority within eight weeks.
The hospital apologised to the patient and her family and said it was “very concerned” that the department concerned had not followed guidelines for reporting the blunder. Pharmacy staff had been reminded to be prudent when dispensing drugs and to report any incidents within 48 hours.
Tim Pang Hung-cheong, of the Patients’ Rights Association, said medics should report blunders even if patients did not report any serious issues.
“It’s like hitting someone with a car but leaving the scene without taking responsibility, which is a more serious crime,” said Pang. “Staff must report blunders immediately through formal ways.”
