SGH acknowledges shortcomings in training and assessment of competency of its nurses after a nurse administered an overdose of anesthetic 10 times the prescribed amount

It was reported in the media yesterday (19 Dec) that an elderly patient, Madam Chow Fong Heng, was accidentally given an overdose of anaesthetic 10 times the prescribed dose at SGH.

The incident happened two years ago. Madam Chow, who was a dialysis patient, was admitted to SGH on 24 May, 2016. Few days later, she was found to be suffering from a rapid heartbeat and the doctor looking after her then prescribed lignocaine to her.

At this point, a staff nurse who was in-charge of administering the anaesthetic drug mistakenly keyed in “41.7” instead of “4.17” into the IV Smart Pump. This resulted in Madam Chow receiving 10 times the original 4.17ml of lignocaine per hour dosage prescribed by the doctor.

This was revealed at yesterday’s (19 Dec) Coroner hearing of Madam Chow’s death. The name of the said staff nurse, however, was not revealed. In the court documents, this staff nurse was only identified as “Staff Nurse C”. It’s not known why her identity was kept a secret.

During the court inquiry, Coroner Marvin Bay maintained that the overdose did not appear to have directly contributed to or hastened Madam Chow’s death. He said she had a history of ailments including hypertension and end-stage renal disease, and found that she died of a natural cause. But he did stress that there are valid areas of concern in this case.

He said, “Nurse C, in explaining her error, indicated that she had no experience and limited exposure to the pump machine, but was nevertheless allowed to operate it.”

“She had, of course, made the gross error in calculations with regard to the amount of lignocaine administered, apparently confusing the application of units of ‘milligram’ and ‘milliliter’… in giving Madam Chow a dose which was effectively 10 times the actual prescribed dose.”

Meanwhile, SGH has acknowledged shortcomings in the training and assessment of the competency of its nurses.

SGH’s chief of nursing, Dr Tracy Carol Ayre, said the hospital regretted the incident even though it did not directly contribute to Madam Chow’s death and “appropriate” action has been taken against the staff involved.

Presumably, Staff Nurse C is will under the employment of SGH.

“We have taken further steps to strengthen our processes in the administration of medication. In the training and assessment of our nurses, steps have been taken to reinforce strict compliance with counter checking when administering unfamiliar medication… System alerts have also been put in place to prompt when there is any discrepancy noted. Staff are to call for help when they encounter pump alert and discrepancy,” Dr Ayre assured the public.

On the matter of training, this year, some of the degrees of the nurses from India have been officially recognised by the Singapore government under the enhanced CECA signed between Singapore and India.

It’s not known how compatible the trainings gone through by the nurses in India are, when compared with those in Singapore. Perhaps Dr Ayre can further assure the Singaporean public on this matter?