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Report details medication mistakes at Alberta Children’s Hospital

CALGARY – A summary of the independent report into several medication errors at the Alberta Children’s Hospital suggests ineffective communication and improper usage of equipment led to the problems.

But the full 58-page report was withheld Tuesday by Alberta Health Services due to confidentiality issues.

The independent report, which was conducted by the Health Quality Council of Alberta, was commissioned to look into four significant medical mistakes at Alberta Children’s Hospital in late February and early March 2009.

It was submitted to Alberta Health Services last fall.

Although the head of the council said the full report should be made public, officials with the hospital said they were only able to talk about the actions they took to improve patient safety.

It includes developing better procedures, making adjustments to equipment and ensuring better communication with staff.

The errors — which aren’t related, but happened on the same nursing unit within a two-month period — included:

• an accidental overdose of a narcotic;

• an accidental overdose of a drug to suppress the immune system;

• a case where a medication was incorrectly administered through an intravenous line instead of through a tube to the stomach; and,

• another incident where a nine-month old baby received the incorrect expressed breast milk.

The errors involved four children whose names have never been released and current health status is not known. No deaths occurred as a result of the mistakes.

Calgary Herald


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