Wrong Injection

Hawke's Bay Herald-Tribune, Issue 133, 22 June 1937, Page 8

Wrong Injection

x-ray patient New Phase Opens in Hospital Inquiry , FRANK ADMISSI0NS Frank adinission by three people directly concerned in the administxation of a particular X-ray in jection that they were unfamiliar with a preparation known as neohydriol which was used instead of abrodil for the injection was made last night before the Royal Commission investigating the circumstances surroundihg the treatment of Mr Saanuel J. Montgomery, of Taradale. The outcome of this wrong injection was that the Hospital Board. settled a claim for £3000 by paying £1000, and later an internal reorganisation was made to provide safeguards against any similar happening in the future. Samuel James Montgomery, pluxnbeT, of Taradale, stated that while a patient in the Napier Hospital in July 1934, he was given a wrong injection, at the .•esult of which he suffered serious illoffects and from which he was still suffering. A writ was taken against Dr. Harvey ahd Dr. Sowersby. As a result witness received £1000 and certain special damages. To Mr A. E. Lawry, witness explained that he was a patient of Dr. J. Allan Berry, who sent him to the Napier Hospital for the purpose of an X-ray and not for any treatment. Witnes3 oxplained that he was put on the table .n the X-ray room when a nurse rubbed iiis arai with cci ton wool with sorncffiiug on it. A nurse brought in a tray and Dr. Maaka proceeded to administer in injection. Dr. Maaka appeared to be n doubt concerning the preparation i.or rhe injection. On raising a question be was told to go ahead. lmmediately on the first prick of the needle, witness nstantly cornplained of a pain he fell letween the eyes. Witness pulled away lis arm which a nurse held. Dr. Maaita hen proceeded with the injection. Ihe jffect which was noticeable between uis cyes at the first prick became most icute. Witness detailed the steps taken afterwards to give him an infusion. He ay in the hospital for a fortnight when ue wae taken to the X-ray room for an X-ray. He suffered considerably from the cold on that occasion and foT tho L'ollowing fortnight suffered great pain Ifife in Danger Mr Lawry explained that u dociot who investigatea the case said thai jlr Montgomery suffered very great pain and that his life was in great uanger. Tne chairman: Whoever is to blame. .Vlr lUontgomery, the commission sympathises with you and hopes that you wiJl recover your health and strength, Mr Foden: He has got a great climate .c assist him. The chairman: He certainly has. "1 wish to make it perfectly cleai -hat Dr. Harvey was away from the wown at the time and took no personai jart in it at all," explained Mr Lawry. ^'He was joined an tne proceedings on pureiy legai grounds.'.' Dr. P. Lynch, pathologist, of Waitngton, detailed at length the composi--ion or neo-hydriol, which was an .odised ester of poppy-seed oil and resembled lipiodal, which wa3 also an .odised poppy seed oil in regard to its i.odised content, but was less viso. ous, de explained that it was possible that -ts lack of viscosity may have confused t ivith abrodil. The chairman: It was a serious miu--ake indeed. Mr Foden: Do you say that it waa a pardonable mistake? Witness: I wouid not say that, as it night be thought that I was condoning what liappencd. Tho chairman: A human mistake. Mr Foden: ln 1934 neo-hydriol was a tiew thing? Witness: It ivas new to mo and 99'J out of 1000 others. Care Not Taken. Mr Foden: All care was not exercised m that occasion? Witness; The results ehow that. Continuing, witness explained tnat oecause of its oily substance it was not ntended to be used intravenously. Mr Laivry: Can you givo Mr Montgomery, who has been suffering severe ifter-effects, an assurance that he can hope that it will be eoinpletely cleared jut of his eystem? Dr. Lynch; I am satisfied that he .von't have any further ill-effects. There s no reason why his circulation should iot be fully re-established and that h« will get quite well again. Mr Lawry: He will be glad to hear hat answer. The chairman: He will be able to :at three meals a day and have a good deep at night after that. Mr Lawry: An abrodil injection waa >rdered. In the preparation of the tray omeone made the mistake in thinking hat neo-hydriol was the drug that did he work of abrodil. Dr. Lynch: L would sooner let the mmmission decide that. In reply to Mr Grant, Dr. Lynch !xplained that with the multiplicity of rado names of preparations made by iroprietary companies, unless great caro vas taken, confusion would result. Mistake Admitted. Sister Genet said she prepared a tray nd put on it a bottle of neo-hydriol i.ud not a bottle of abrodil as directed. t was a mistako due to witness 's guorance of the use of tho two drugs. )r. Maaka spoke to witness about tho lottle on the tray and af.ked her if t was the "right stufl1," and she redied that "she thought it was." Witess took the bottle from a cupboard n the ward. Witness heard Dr. Sower■y say, "Give 20 c.c.," and Dr. Maaka jave the injection. Sbo could not re«11 the two doctors discussing tho cou-

' tcnts of the bottle. • To Mr. Grant witness said that at the timo she was a charge. nurse, and it was her duty to prepare a number of trays. There were a number of new preparations about at the time. She thought both the preparations were an iodine solution. The mistake made by , witness was that she thought the one was practlcaily the same as the other. ! Further questioned witness said that j there had been a change in the system of distributing the drugs, and it was now necessary to obtain the majority of them from the dispensary on production of an order, and not from tho ward loeker. Dr. Golan Maaka said that ho saw tho bottle of neo-hydriol and questioned ': tho nurse about it. She replied • that ; she took it from the ward locker and that it was a substitute for abrodil. He replied that he would see Dr. Sowerby and the nurse said she would go to the dispensary. However, as far as he was aware the nurse did not go to the dis1 pensary. When Dr. Sowerby came on the scene witness asked him if "this is the stuff," and he appeared to be satisfied. Witness was not altogether satisfied about the neo-hydriol. Witness mjected the substance and had given about 10 fi.e. when the patient eomplained. Witness went to the dispensary to ascertain what was in the preparation. I Mr. W. E. Bate, representing the Hawke's Bay Hospital Board: Was . there anything on the bottle to indicate its use? | Witness: No. ; Did the label give its ingredients? — "Not that I can recall." "A Frauk Witaess." ; Dr. William Sowerby, uiedical practitioner, now practising as radiologist at Timaru, was next calied, and said that when I^r. Maaka asked him about ueo-hydriol and abrodil witness replied that he did not know if they were the same. Witness had not heard of neo- | hydriol, having never conie across it | before. Witness«returned to the X-ray ! room and later Dr. Maaka asked him how much to give. | "I pieked up the bottle, glnnced at ; the bottom of the label and saw 20 c.c. land told « him Ihat," said witness. "I i did not look at tho label properly . . . unfortunately. " Mr. Foden: Did not Dr. Maaka men- • tion neo-hydriol? j Witness: Yes. j And you knew nothing about it? — i "That is so. " I Then should not that very fact have 1 warned you? — "It should have." The chairman": You certainly are an ; honest witness. Continuing, witness said that it was i uot until the patient began to cough t and Dr. Maaka asked if witness was quite sure it was ,the "right stuff," I that witness took- the bottle a seeond • time and aetually read the name on the I label. He realised then that it was • being wrongfully used and told Dr. . Maaka to dis'continue the injection.