Finding into death of Eddie Teck Chuan Lee
Deceased
Eddie Teck Chuan Lee
Demographics
66y, male
Date of death
2008-04-12
Finding date
2014-01-21
Cause of death
Intracerebral haemorrhage
AI-generated summary
A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreading heparin ampoule concentrations during a busy night shift. The two available ampoules (5,000 and 25,000 units) were identical in size and shape with only colour-coded text differentiating them. Although the error was immediately recognized and the infusion stopped, a CT scan showed progression of the intracerebral bleed. The coroner found a causal link between the overdose and death. Systemic failures included similar-looking ampoules, inadequate double-checking (nurse was alone when administering), and busy staffing levels. Post-incident improvements included pre-prepared heparin infusions and reinforced medication checking protocols. The coroner did not make adverse findings against individual nurses but highlighted the risks of mental arithmetic during busy shifts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Accidental tenfold overdose of heparin (20,000 units instead of 2,000 units)
- Similarity in appearance of heparin ampoules (5,000 and 25,000 unit vials identical in size and shape, differentiated only by colour-coded text)
- Nursing staff misreading of ampoule concentration
- Busy night shift workload
- Inadequate double-checking of medication (nurse administered alone despite protocol requiring two nurses)
- Insufficient communication of clinical complexity to nursing staff
- Lack of protamine sulphate administration after recognition of overdose
Coroner's recommendations
- Removal of 25,000-unit heparin ampoules from ward stock (ampoules to be ordered through pharmacy only when required)
- Introduction of pre-prepared heparin infusion bags with saline instead of manual preparation
- Reinforcement of medication administration protocols with all staff to follow without exception
- Introduction of protocol for single-administration medications deemed lower risk, while maintaining double-check requirement for high-risk medications including heparin
- Further staff education in performing consistent and reliable Glasgow Coma Scores
- Improved communication of clinical complexity to nursing staff, particularly regarding patients with multiple competing conditions
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