Because the doctor “was travelling”, a child received a double dose of chemotherapy at Oslo University Hospital the Norwegian Health Authority concluded.
Child received double dose of chemotherapy at Oslo Hospital
The drug, Lomustine, should only be administered at a dose every six weeks, but the mobility at the Oslo University Hospital (OUS) department led to a double dose being given a child.
“The doctor who prescribed the medication was busy and was called for other urgent
tasks,” he said in the report from the medical supervision referred to by Dagens Medisin publication.
It also appears that the nurse responsible for giving the drug to the patient did not know that the substance should only be given once and had no sufficient expertise to detect the defect.
“Such an overdose can lead to serious consequences for the patient, but in this case, the event did not cause serious consequences,” the audit said.
Changes to routines
The Norwegian Public Health Authority has concluded that Oslo University Hospital did not ensure proper health care when a child with a brain tumour had to be treated. They also concluded that there was no guarantee of proper assistance after the error was discovered.
The Norwegian Board of Health and Welfare pointed out that nurses have an independent responsibility for ensuring that they provide medication properly, even where the doctor may be in the wrong.
Oslo University Hospital has announced that they have changed routines and strengthened training to reduce the risk that something similar happening in the future, wrote Dagens Medisin journal.