Finding into death of Eddie Teck Chuan Lee

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

1. Removal of 25,000-unit heparin ampoules from ward stock (ampoules to be ordered through pharmacy only when required)
2. Introduction of pre-prepared heparin infusion bags with saline instead of manual preparation
3. Reinforcement of medication administration protocols with all staff to follow without exception
4. Introduction of protocol for single-administration medications deemed lower risk, while maintaining double-check requirement for high-risk medications including heparin
5. Further staff education in performing consistent and reliable Glasgow Coma Scores
6. Improved communication of clinical complexity to nursing staff, particularly regarding patients with multiple competing conditions