Patient Harm Reported Following Medication Error in Västmanland Region
Region Västmanland has filed a Lex Maria report detailing an incident where inappropriate drug treatment led to a patient at a retirement home requiring inpatient care and facing a risk of serious kidney failure. The incident stemmed from a failure to adjust medication dosage based on the patient’s pre-existing reduced kidney function, and a subsequent disregard for hospital recommendations to lower the dose.
the region’s examination revealed the medication was initiated without proper consideration of the elderly patient’s known impaired renal function by the responsible primary care physician. Furthermore, advice from specialist healthcare professionals at the hospital to reduce the medication dosage was not followed.
This resulted in the patient receiving an incorrect dosage,compounded by insufficient follow-up care. Consequently, the patient required end-of-life care and was at substantial risk of developing severe kidney failure.
Region Västmanland reports that the incident caused unnecessary suffering to the patient and posed a risk of serious injury. To prevent similar occurrences, the involved care unit has implemented stricter routines and is conducting educational initiatives for staff.
“Every patient who is injured in healthcare is one to much,” stated Region Västmanland in its release. “Therefore, Region Västmanland has a zero vision in patient safety work – no patient should be injured in health care.”
Lex Maria requires all healthcare professionals to report serious errors or potential harm to patients. The purpose of these reports is to facilitate investigation and learning within the healthcare system, ultimately improving patient safety and providing clarity to those affected.
For more information, contact:
Johan Nordmark, chief physician
Tel: 021 17 46 41
Region Västmanland notes that while the vast majority of its 4,000-5,000 daily healthcare contacts are prosperous, reporting incidents like this is a crucial part of its systematic effort to enhance patient safety.
