KKH medication blunder: Khaw dismissed worker fatigue as cause
November 17th, 2009 | 
Author: Written by our Correspondent
Health Minister Khaw Boon Wan had dismissed the likelihood of worker fatigue as a cause for the medication blunder at Kandang Kerbau Hospital which has taken the entire nation by storm.
Two cancer patients, Mrs Poh and Mrs Ng were given chemotherapy drugs over a few hours instead of days via a calibrated infusion pump.
The pharmacists involved in delivering the drug had apparently mistook the pump for another one which is supposed to infuse the drug over a few days.
When asked whether disciplinary action would be taken against the two pharmacists, Mr Khaw quickly jumped to their defense, saying that investigations are still ongoing and they are personally “very traumatized” by the mistake.
Mr Khaw laid the blame on the similarity in appearance of the two pumps which were mixed up, and said that he would be providing feedback to the manufacturers.
He said:
‘The pumps look almost exactly the same…This is very dangerous when there are two pieces of equipment and one is millilitre per hour, and one is millilitre per day – you are causing unnecessary risk to the users of this device.’
The key thing, he emphasised, is to learn from this incident and prevent similar mistakes from occurring.
It was not revealed how long the pumps have been in use or if the pharmacists are given adequate training in how to prime them.
Though he urged KKH to “treat the patients and their families with fairness”, Mr Khaw did not offer any sympathies or apologies to the victims.
KKH called a press conference last Saturday to explain how the mistake occurred to the public. Its CEO Prof Ivy Ng, who is incidentally the wife of Education Minister Dr Ng Eng Hen had remained silent on the matter so far.
Singapore has one of the best healthcare systems in the world and Mr Khaw was praised by Senior Minister Goh Chok Tong as being the “best” health minister Singapore ever got.
Such medication mistakes are actually not uncommon in Singapore public hospitals where junior doctors and nurses often have to work for long hours with little or no rest.
They are usually not leaked out to the press. It was reported that a relative of one of the patient informed the Straits Times on the matter whose health correspondent subsequently wrote an article on it.
One of the patient, Mrs Ng, had been discharged from the hospital. According to KKH, the medication she was given can be given as an infusion over 15 minutes.
The other patient, Mrs Poh is still warded under observation. She is out of danger yet.
Mr Khaw added that if the harm done to the patient was not ‘irreversible’, ‘we can heave a sigh of relief’.
It is not known if the patients are contemplating taking legal action against KKH for the blunder.
Posted in Editorial
Hospital staff are damn aloof. Feedback is taken as complain and dismissed.
How many times I complain about the problem with items of different intensity been package similarly. What have they been doing? They hack care, think I am talking nonsense. So now this is the first incident. Many more will come.
i don’t think you can blame the pump mfg because measuring units should be specified on the pump, the only thing is whether they could have make it more prominent. KKH can sue the mfg if they think they have a case which i doubt so.
“we can heave a sigh of relief”
Khaw should count his lucky stars that the patients are alive and that they are willing to forgive KKH.
Taken the country by Storm? to be honest, Ris Low news was bigger.
You know, this could be an ‘oops’ euthanasia attempt.
It is good that health minister Khaw Boon Wan has now acknowledged that the infusion pumps are a problem.
I have previously written “When two types of infusion pumps with very different infusion rates are both available for use, it becomes imperative that the two pumps be made as different as possible, e.g. with different color codes and/or different connector sizes and other attributes. Are they? An electrical analogy illustrates: by design, it is impossible to mistakenly fit a standard 13A household plug into a 400A industrial sleeve.” as a comment to http://www.temasekreview.com/2009/11/15/kk-hospital-in-pr-overdrive-to-limit-fallout-from-medication-error/
While this identification implicates the pump manufacturer, it does not absolve the KKH, being the healthcare provider, from responsibility. It raises some concern that such an obvious issue was not discovered in any safety review/audit at KKH or other hospitals before this incident.
Were pharmacists PRs who didn’t understand English?
‘Anyone who believes nothing can or will go wrong in Singapore is living in a make-believe world.’ – MM Lee
“The pumps look almost exactly the same…”
Anybody got pics?
Of course he would admit fatigue was the cause….becos that would mean he cock up in the planning.
So the CEO is the wife of a mini-star. See….this kind of HUGE benefits-in-kind should be taken into account for determining ministerial salary. A minister’s entire family will benefit immensely from his position of power. That alone is worth several million dollars!!! So why should we double pay that minister???
I meant “of course he would NOT admit…”
What kind of excuse is that. An obviously dumb excuse.
Didn’t the manufacturer of the pumps sent some manuals as to how to use the pumps?
Didn’t the manufacturer sent someone to brief the hospital staff on how to identify and use the pumps?
Why didn’t the hospital staff make some Warning Marks/Signs on the pump machines in the first place? Isn’t is an obvious neglect to safety and carelessness on the part of the hospital and the staff?
Come on, Multi-millionaire Minister Khaw, you should do better than that!
A bad workman blames his tools!
given that we take the minister’s words for it,how about giving us more details like if the carlessness was by a local
staff of FT?
There is no ill intent from the two pharmacists, but grave mistakes on their parts which may cause death or permanent damage to vital organs. Discipline actions to be taken, yes should be dealth with, however lightly or severly? If the patient dies, the guilt will be borne by the two pharmacists for the rest of their life. That’s punishment enough. Compensations should be paid KKH whatever the outcome
Blame those manufacturers for the device. Its they and not us.
Instructions were in English only and the pumps look almost exactly the same – so, they must have at least 2 or 3 languages for Singapore hospitals.
But there are certainly many more countries using similar devices in more cosmopolitan cities than Singapore. Yet, they make no mistakes.