'Expired' IV Fluid Issue: Preliminary Probe Points to Human Error

Jan 13, 2025

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A preliminary report submitted by a 13-member expert committee that is probing the alleged use of "expired" IV fluids at Medinipur Medical College and Hospital (MMCH) has pointed to "human error" and procedural lapses as contributing factors. The incident resulted in the death of one woman and left three others critically ill after childbirth.

Key Highlights:

  • Preliminary Findings:

The expert committee recommended that the primary factors for the deteriorating health of patients were human error and the side effects of "other medicines" with minimal roles by the Ringer's Lactate (RL) fluid.

  • Procedural Lapses:

The report cited mistakes in the injection of Oxytocin injections, a medication to stimulate labor contractions and prevent excessive bleeding after delivery.

  • Absence of Senior Staff:

All the senior medical staff were absent when the incident took place and all the delivery cases were left for treatment by the trainee medics.

  • RL Fluid Contamination Ruled Out:

The same batch fluid was administered on other patients also, and so far no adverse effects have been reported; hence, contamination is ruled out.

  • Health Department's Response:

A 13 member panel was constituted to probe into the incident. The preliminary report of the panel was presented to Chief Secretary Manoj Pant.

  • Statements from Leaders or Officials:

A health department official noted, “The initial findings indicate human error and procedural lapses, including issues with Oxytocin administration. Further investigations are underway, and we await the final report from the drug control unit.”The health department is waiting for the final report from the drug control unit to confirm the role of the IV fluid and other medicines in the incident. Meanwhile, three critically ill patients have been shifted to SSKM Hospital in Kolkata for advanced care. The case has highlighted the urgent need for stricter protocols and improved oversight in government healthcare facilities to prevent such incidents in the future.

human error in healthcare
Oxytocin injection issues
health department probe
human error in healthcare
Oxytocin injection issues
health department probe

'Expired' IV Fluid Issue: Preliminary Probe Points to Human Error

Jan 13, 2025

A preliminary report submitted by a 13-member expert committee that is probing the alleged use of "expired" IV fluids at Medinipur Medical College and Hospital (MMCH) has pointed to "human error" and procedural lapses as contributing factors. The incident resulted in the death of one woman and left three others critically ill after childbirth.

Key Highlights:

  • Preliminary Findings:

The expert committee recommended that the primary factors for the deteriorating health of patients were human error and the side effects of "other medicines" with minimal roles by the Ringer's Lactate (RL) fluid.

  • Procedural Lapses:

The report cited mistakes in the injection of Oxytocin injections, a medication to stimulate labor contractions and prevent excessive bleeding after delivery.

  • Absence of Senior Staff:

All the senior medical staff were absent when the incident took place and all the delivery cases were left for treatment by the trainee medics.

  • RL Fluid Contamination Ruled Out:

The same batch fluid was administered on other patients also, and so far no adverse effects have been reported; hence, contamination is ruled out.

  • Health Department's Response:

A 13 member panel was constituted to probe into the incident. The preliminary report of the panel was presented to Chief Secretary Manoj Pant.

  • Statements from Leaders or Officials:

A health department official noted, “The initial findings indicate human error and procedural lapses, including issues with Oxytocin administration. Further investigations are underway, and we await the final report from the drug control unit.”The health department is waiting for the final report from the drug control unit to confirm the role of the IV fluid and other medicines in the incident. Meanwhile, three critically ill patients have been shifted to SSKM Hospital in Kolkata for advanced care. The case has highlighted the urgent need for stricter protocols and improved oversight in government healthcare facilities to prevent such incidents in the future.

Share:

human error in healthcare
Oxytocin injection issues
health department probe
human error in healthcare
Oxytocin injection issues
health department probe