Mother dies after nurse makes error administering drug

Article from the Daily Mail 23 February 2011

In true Daily Mail style the story is hyped under the title "Mother-of-four dies after blundering nurse administers TEN times drug overdose"

80 year old Arsula Samson died on 14 March 2010 at Good Hope Hospital, Birmingham after she was given an overdose of deadly potassium chloride.

According to the inquest staff nurse Lisa Sparrow wrongly administered 50ml of the drug over half an hour instead of over five hours, the inquest heard.

Instead of pressing the 10ml per hour button, the nurse admitted tapping in 100ml per hour on the drug infusion pump.

Staff nurse Sparrow signed out the medication from the controlled drug stock cupboard with staff nurse Susan Smith, as two people were supposed to administer and check the drug together to avoid any errors under hospital policy.

But nurse Smith left nurse Sparrow to give the drug on her own when the error happened. The coroner said that nurse Sparrow's gross failure resulted in the overdose and was a direct cause for the death while a second failure was that nurse Smith did not oversee the drug being given.

Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death

Mrs Samson was suffering from pneumonia when she was given the massive overdose that led to her death

Nurse Sparrow told the inquest she had not expected nurse Smith to watch her give the potassium as 'no-one ever did'.

An official Trust report said no error was found with the infusion pump and investigators ruled the death was due to 'individual, human error'.

A Trust action plan after the death saw new infusion pumps and software that reduce the risk of error brought into all wards, medical staff retrained and warned over the dangers of potassium chloride and advice on the importance of a second nurse witnessing medication being given.

Birmingham coroner Aidan Cotter gave a verdict of accidental death to which neglect contributed.