Pharmacist here. Firstly, sorry to hear this has happened and hope your mother in law is on the road to recovery from what she has experienced. It does appear to be a fairly clear case of negligence causing harm. Also agree that if this was assessed and given a risk score in a system like DATIX it should be high enough to warrant thorough investigation. My main issue here is the brushing off of it by the doctor.
As for the error itself, I have actually seen an almost carbon copy of this error happen before. I was working in medicines information at a community trust and got asked for advice about potential adverse effects from a patient being given a dose of hydrocortisone intramuscularly instead of hydroxocobalamin (B12). In this case the patient suffered no harm but it was fully investigated and I expect there will be many parallels with your incident.
As alluded to by scardypants, the medicines would most likely be located next to each other on the dispensary shelf and it would be a picking error by a dispenser. The pharmacist should of course have picked the labelling error up when it was second checked, which I am almost certain it will have been, although obviously not to the right standard in this case.
Checking dispensed medication is a horrible combination of being a high volume repetitive task that is being done in a highly pressured environment with lots of interruptions and distractions, but where you need to be very focussed and accurate. I have made checking errors in the past and when they come back and you look at them in the cold light of day, you wonder how you missed it, but then you think back to the environment and what was going on at the time and then you realise how these things occur. My first question would always be ‘is the patient ok’…and then you pray. I’ve been lucky but that’s all it is. I think published error rates for dispensary accuracy checking are about 1% but with the pressures on the health service, which are as severe in pharmacy as anywhere else, you might expect that to creep up.
It will most likely be the same story with the nurse. You will probably be aware in the news of all the pressures in the ambulance service and hospitals with bed blocking, so there will be a huge push to get patients out into the community to be managed by district nurses. I don’t know for sure, as not worked in that sector for a few years, but I would be fairly confident that the numbers of visits DNs are expected to do in a day will be going up and up and again you might expect to see error rates rise.
There is something called the Swiss cheese error theory. Each check in a process is a defence against an error occurring but they are not perfect and are likened to a slice of Swiss cheese with holes in. If an error is made in one check and it gets through a hole in the Swiss cheese, then it usually gets stopped by the next one. Errors like this occur when all the holes line up. As pressures grow, sadly there are more holes and they’re getting bigger.
Of course none of what I have described above is to excuse what has happened but just to give some context as to what might have been factors. It does need to be investigated to identify any systems issues that can be addressed at a minimum. As you have have suffered quantifiable financial loss as a result of the error then you have every right to pursue that so you can be compensated. How hard I would pursue I think would depend on the responses from the organisations and individuals involved. I would expect the pharmacist and nurse to be mortified, as I would be. I would be concerned if there was any attempt to brush it off rather than to express sincere regret and to apologise and look to what lessons could be learned.
Sorry again to hear of this and hope you get to a resolution and that your mother in law is ok.
