WRONG LABEL

Otago Daily Times, Issue 26635, 4 December 1947, Page 4

WRONG LABEL

INJECTION SOLUTION DEATH OF HOSPITAL PATIENT INQUEST AT AUCKLAND P.A. AUCKLAND, Dec. 3. Finding that the cause of death of an elderly man in the Auckland Hospital was due to an injection of an aromatic petroleum distillate in the belief that it was a dextrose solution, the coroner, Mr A. Addison, commented at the inquest that it was pleasing, to note that the hospital authorities had taken steps to prevent the recurrence of such an accident. The inquest concerned the death of Edgar Stanmore Day. aged 74, in hospital on October 12. A fully trained nurse in the ward where Day was a patient. Miss E. T. L. Pagonis, said that when she noticed that the bottle from which he was receiving an intravenous injection was nearly empty she went to a cupboard where full bottles of dextrose solution were kept to replace it. There were three full bottles with the seals off and several other sealed bottles of saline solution. She replaced the nearly empty bottle with a full one of dextrose. It was filled to the correct level. Full but unsealed bottles were used at times. The seals were sometimes removed, but the bottles were put back unused when the treatment was changed. • Smelling Test Prohibited

There were no sealed bottles of dextrose in the cupboard at that time, said witness, and there were no instructions against using unsealed bottles. Nurses were not allowed to sniff the contents of bottles as they would then be considered unsterile. Since that time instructions had been issued that only sealed bottles were to be used. After about half an hour she had smelt a strong small like floor polish, said Miss Pagonis. She thought it was from the polish on the floor. The drip apparatus did not appear to be functioning correctly and she made several efforts to rectify it A doctor and a surgeon arrived shortly afterwards, and both attempted lo rectify it also. Soon after this Day collapsed, and m spite of the use of stimulants he died. When laying out the body, witness and another nurse found that the. bottle and apparatus used had contained some thing like- kerosene. She had no idea how it came to do so, as it was properly labelled. , , _ The physician who attended Day rn the ward, Dr J. D. Allen, said that when he and the surgeon saw the patient they adjusted the drip apparatus which was not functioning correctly. They noticed nothing wrong otherwise. While on his round of the rest of the ward he was recalled to Dav who had collapsed and later died soon afterward. He Was informed by the nurse that she thought there had been kerosene in the bottle and he realised that several ounces of fluid must have been injected into the circulation of the patient.

Questioned regarding safety precautions with the use of intravenous injections, Dr Allen admitted that injections would be highly "dangerous if the wrong substance were used; If sealed bottles were always used, however, that would be an adequate precaution, as the seals would be considered a guarantee of the purity of the fluid.

He did not agree that it would be necessary to keep the bottles in a locked cupboard provided only sealed bottles were used, and an instruction from the authorities had now been made to this effect. The ward sister. Miss B. Bennetts, explained that deliveries of dextrose were made each week to maintain the store in the ward. Kerosene or turpentine would only be used by orderlies or cleaners in wards, and while they could go into the room where dextrose bottles were kept, they would only do so for cleaning purposes. The detective who investigatedthe case said he had been unable to find out how' petropine got into the dextrose bottle. There was no evidence, however, of criminal negligence on the part of anyone concerned. Danger Not Realised " It is quite clear that the contents of a bottle labelled ‘dextrose’ were used on the assumption that it was true to label,” said the coroner, “whereas the contents proved to be petroleum distillate. The placing by some unthinking, careless person of this fluid in the dextrose bottle without removing the label must have been done without realisation of its effects.” Adding that he was pleased to note that only sealed bottles were now being used, Mr Addison said he thought that if this rule were strictly adhered to it would effectively close the avenues for further accidents of such a nature. A verdict was brought in in accordance with the. medical evidence, that petroleum distillate had caused a blockage of the heart.