Who nearly killed John ak Doe?

Yesterday I reviewed the case of a middle aged Iban man who was admitted to the ward with severe hyponatriemia and hypokalaemia.

Turned out that the reason for his extremely low sodium and potassium level was that instead of being given Potassium Chloride to complement his Frusemide (a diuretic), he was erroneously given  Hydrochlorothiazide (another diuretic) tablets in a village government clinic. So basically the drugs were merrily helping him to get as much salt and water out of his body as possible for the past fortnight.

To add salt to the injury, he was actually not indicated to take Frusemide and Potassium Chloride for the past eight years as they were already stopped by a Medical Officer. However this fact was neglected by subsequent Medical Assistants who reviewed his case and happily treated him with the wrong drugs for eight long years, leaving the poor patient with reduced quality of life all these while (he complained of the need to urinate a few times in the morning due to Frusemide) and ultimately a near death experience.

Even as we thank our lucky stars that he didn’t slip away, questions had to be asked on how we collectively as healthcare professionals, let this happen. Should we just put the blame solely on the offending person who fill the meds, or is it more of a systemic error?

While doing my research study on patients here, I realised that most longhouse dwellers, despite having little ideas on what their medications are for, took them devoutly hook, line and sinker, no questions asked. They entrusted their life to us healthcare workers fully, but does we ever realise or value the trust they put on us?

Sometimes I think we are so mired in the routine-ness of our work and our busy schedule and own problems that we lose sight of the forest for the trees. We just treat the current complaint of the patients, without an iota of awareness that perhaps we need to take a step back, flipped through the whole medication file and understand the whole picture. We failed to appreciate the fact that they put their faith on us to get it right, and yet we treat them as cases to be sent out of the revolving doors of the clinic or pharmacy ASAP so that we can see the next patient and meet our waiting time Key Performance Index.

As wrong as it may sound, sometimes I wish these incidents happen or get detected more often, as it serves as a timely reminder on the real purpose of our job. No matter how good is our waiting time, how tidy our paperwork, and how much praise we get from our pencil pushing bosses for that, ultimately I think the one higher up there is judging us on how many lives we managed to save. And that is what we should constantly reflect upon and bear in our minds.

From this poor man’s misfortune, I contemplated and  learnt a valuable lesson; and by sharing it, I hoped that at least he didn’t suffer in vain.