Wrong meds blamed for man's coma

When her 74-year-old grandfather went to the emergency department Jan. 27 with flu-like symptoms, Victoria Clarke never imagined that his liver cancer diagnosis was not the worst thing that could happen during his 53-day hospital stay.

On Feb. 18, while in the Family Medicine Unit at the University Hospital of Northern B.C., Anthony Webb was given medication that was not prescribed to him, according to Clarke.

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Those drugs put him in a heavily-sedated, comatose-like state for three days, she said.

The three extended-release morphine pills he wasn't supposed to take were given to him by a registered nurse on duty that night, she said.

They were meant for another patient who was in a decade-long battle with bone cancer.

To try to counter the effects, Webb was given Narcan, a prescription medication which blocks the effects of opioids and reverses an overdose.

"I'm sure that dosage would have killed him," Clarke, a Prince George social worker, said.

"I can't say it's a lethal dose but I'm sure it was because otherwise they wouldn't have given him the Narcan."

Clarke said Webb woke up from his drug-induced coma on his 75th birthday.

"What happened to my grandfather isn't right and it's happening to other people," Clarke said tearfully. "People are dying every day. He could have died. It's not right what they're doing. It's just so sad."

Clarke said she believes the error occurred because the nurse did not confirm Webb's identity to make sure the patient's name matched the one on the order before giving him the medication.

B.C. Nurses' Union chair Veronica Lokken did not return a phone call requesting an interview.

Andrea Palmer, Northern Health's regional manager of public affairs and media relations, said because of privacy and confidentiality legislation she could not comment on this situation.

"Northern Health does have a policy on medication administration and there is a process to address deviation," Palmer said.

"I can't give you a single answer around medication administration because it's different in different cases. There isn't a single answer. It depends on the patient, the illness, and the medication being delivered."

According to a recently published report from the Canadian Institute for Health Information (CIHI) called Measuring Patient Harm in Canadian Hospitals, roughly one in 18 patients suffered harm in Canadian hospitals in 2014-2015. One in eight hospitalizations where a patient experienced a harmful event resulted in death and one in five that experienced a harmful event had more than one event occur.

The report defines a harmful event as a preventable but unintended outcome during care that is identified and treated within the same hospital stay.

In 2014-2015, the most common harmful events were in medication-associated conditions at 37 per cent, healthcare-associated infections at 37 per cent, procedure-associated conditions at 23 per cent and patient accidents at three per cent.

"I can't report out for Northern Health because those numbers are only being reported nationally," said Palmer.

"The thing with CIHI and the Canadian Patient Safety Institute is that they're working with a new measure and with provinces and facilities on their methodology to ensure the information is properly comparable across jurisdictions, and right now it isn't and so right now the information is only being reported publicly at the national level."

During his hospital stay, Webb was diagnosed with untreatable liver cancer and had a tube surgically inserted to allow toxins to flow from his body.

When it was discovered the first tube was too small, a larger tube was inserted.

He got an infection that he was prescribed antibiotics to combat as a result of the second surgery.

When Webb fell trying to get to the bathroom one day, the second tube came out. It was changed during another surgery for a tube that was implanted into his body.

Webb was given the three extended-release morphine pills two weeks after having the second tube inserted.

The day after Webb was given the morphine in error, Clarke went to visit her grandfather.

"That nurse was still working there at the same desk," said Clarke, who told the nurse that she was sorry she had to be on duty with Clarke's family looking at her, knowing what she had done.

Clarke asked to speak to the Family Medicine Unit supervisor.

After a two-hour wait, Clarke and the supervisor met.

Clarke relayed the details of how the conversation went the night before that led up to Webb being given the wrong medication.

When the nurse first offered the medication to Webb, he was with his grandson, who wishes to remain unidentified. Both Webb and his grandson questioned the administration of medication, because Webb hadn't been on any pain medication for at least two weeks and each wondered why he was to take it now. The registered nurse said that Webb didn't want to wake up in pain, and Webb took the medication.

Webb and his grandson continued to discuss the matter and just to be on the safe side Webb's grandson went to the nurses' station to make sure the morphine was meant for his granddad. It was not.

Clarke was shocked by what the supervisor said during their meeting.

"So I was told it was my grandpa's fault that he took the medication because he should know what medications he's on," said Clarke.

"And she said this happens all the time in the hospital - giving the wrong medication to someone happens all the time."

So Clarke asked what happens when the wrong medication is given.

"And she said 'we don't have anything in place,'" recalled Clarke, who then asked if the nurse would be retrained, reassigned, supervised or suspended.

"She told me none of that would happen, that she did willingly sign the serious incident report, did admit to doing it - not checking his bracelet (to identify him) and giving him the wrong medication, but that's as far as it goes."

Clarke asked for a copy of the serious incident report but was told she'd only get it through a lawyer.

Clarke was told by another team nurse that they would have a family meeting to discuss protocol and explain how policy worked. She's still waiting for that meeting.

Northern Health offered this explanation: "In situations where there may have been a medication administration error our practice is to address the patient harm immediately, and disclose the error to the patient or family if the patient is not able to hear the information or be communicated with, along with our plan and process to investigate an incident," Palmer said.

"When errors are made, what we strive for is a culture of safety, which includes a no-blame, no-shame approach and the goal of that is to ensure that individuals are open and transparent when an error is made. That does not mean staff is not accountable for an error."

Clarke reached out by email to a supervisor she believed was above the Family Medicine Unit supervisor she spoke with, but there was no response. She then reached out to Northern Health's Patient Quality Care office over the phone. Clarke said she spoke with a woman about the incident for a half hour and the woman was kind and said she was sorry about what had happened. Clarke was expecting a follow-up call and when it didn't come she emailed the same person so it was documented with a response back. The reply stated that the manager of the unit was made aware of the incident, but that Webb would have to lodge a complaint himself.

When Webb awoke on his 75th birthday on Feb. 21, he was very upset about being given the wrong medication.

Clarke said Webb was afraid there would be repercussions if he made the complaint and wouldn't even let the family discuss the matter at the hospital because he was afraid the staff would hear. So the family focused on his care because he wanted to be out of the hospital as soon as he could manage.

The patient plan for Webb was that he would get his strength back in order to be able to leave the hospital to live his remaining days as he chose.

Clarke said that about two weeks before he was discharged, Webb had a panic attack and a nurse tried to calm him down by assuring him he was only having a panic attack. She provided details about what his breathing would be like if he were dying, thinking it would offer comfort, Clarke said.

Instead, Webb was left in an even more upset state and he called his daughter and best friend at 3 a.m. to be with him, begging them to never leave him alone.

"He was scared out of his mind and crying," said Clarke, who along with the rest of his family rallied around Webb and between several adult family members they took shifts so he wouldn't be alone.

Webb was discharged from hospital on March 20.

He died on April 6 at 3:13 p.m. at the home of his best friend.

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