Heparin overdose at hospital kills Australian man
November 25th, 2008 by Jennifer Walker-Journey
A lack of communication among hospital staff lead to an inappropriate injection of heparin that lead to the death of an Australian man earlier this year, according to Hawke’s Bay Today.
The victim, who had complained of chest pains for three weeks, was admitted to Hawke’s Bay Hospital in January. Doctors diagnosed him with unstable angina and administered Enoxaparin, a low molecular weight heparin manufactured by Sanofi-Aventis. A half-hour later he was diagnosed with acute lateral myocardial infraction, or a heart attack, and was given another dose of heparin. Within hours, the overdose caused his gums to bleed and his brain to hemorrhage. He died early the next morning.
A cardiologist’s review said that the lack of communication among hospital staff and a delay in seeking advice from the medical registrar was likely the cause of the overdose, which lead to the large, intracerebral hemorrhage that brought on the man’s death. Heparin should not be given to patients less than 12 hours after Enoxaparin.
The coroner’s report did not lay blame on any one medical staff member, however it did show areas for improvement in the treatment. The Hawke’s Bay District Health Board followed up with an extensive review in an effort to improve patient safety and communication among dempartments. As a result, Hawke’s Bay Hospital has implemented treatment protocols for heart attacks among hospital staff and more emphasis is being placed on improving communication between the emergency department and coronary care staff.