At just the age of 18 a patient appeared to have taken an overdose of paracetamol after his mother found an empty paracetamol container in his room, next to his bed, which was full the night before. At the time the patient was already receiving psychiatric therapy for previous issues.
It was believed that the patient took the drug no more than 10 hours beforehand. The patient was set to take a blood test to check his levels (make sure everything is fine.) the results were later sent to the hospital.
A nurse and a technician got a hold of the results and the levels were very low for salicylate. They began to make notes on the paracetamol levels. The technician didn’t state explicitly how toxic the levels were or if the nurse understood. He assumed she knew what these results meant and this lead to a huge communication error.
The results on the graph said 2.13 for the levels which was way below the levels required. The nurse then enquired about these levels with graph and then was informed that the patient would be staying in the hospital overnight.
She brought the results to the notice board and began to carry out what was needed for the patient. The technician left before the printout came back from the lab. The print out stated that the level of paracetamol was 213. This was not discussed in time and 2 days later the patient was having serious liver problems.
1 week later the patient died all because of a lack of communication in the hospital. This is why we need to communicate properly and learn from this. Working in labs and hospitals is very serious.
How these problems could have been avoided:
All staff and workers should be given a full induction and explanation behind how to communicate in the hospital. It should not be optional and these places should record who attends which meetings. If someone can not make one induction they should be forced to attend a different one. This way everyone knows what to do, say and how to act in the lab or hospital.
Doctors or any kind of staff should be well aware of the importance of recording data in the workplace and should be educated on storing data as well as interpreting it.
Staff should be encouraged to ask questions to seniors if they have any concerns especially when they are first in the role/job.
Hospitals and labs should review their communication policies especially for test results. This could mean setting up suitable phone lines in each ward or just increasing the amount of emails which are sent and received.
All results should be double checked by different workers in that department. Results also should be taken more than once by entirely restarting the process which generates results in order to get very accurate results.
Make sure staff do not work beyond their set amount of working hours unless it is extreme circumstances. You want all staff to be fully focused on what they are doing, one lack of concentration could be fatal.