A 29-month-old baby boy was in critical condition after receiving an overdose of a cardiac drug from a pediatrician at Prince of Wales Hospital, the Hong Kong Economic Journal reports.
The apparent case of medical blunder took place on Sunday night, when the baby, who has a congenital heart defect, was sent to the accident and emergency (A&E) department of the public hospital in Sha Tin due to fever and shortness of breath.
The baby’s condition worsened and led to a heart failure with his Glasgow Coma Scale reading dropping from 15 to 6 and his heartbeat slowing down.
At around 8:30 p.m., the pediatrician on duty decided to inject atropine, a cardiac drug, into his system in a bid to revive him.
However, the injection only led to a worsening of his condition.
The doctor performed emergency measures, including cardiopulmonary resuscitation or CPR, injection of adrenaline, and use of automated external defibrillator, until his heartbeat returned to normal.
A review of the baby’s medical record by A&E nurses showed that the baby had been given 1.56 milligrams of atropine, five times the recommended 0.26 mg.
The baby was transferred to Queen Mary Hospital at 1 a.m. Monday.
According to RTHK, the incident has been reported to the Hospital Authority as a “serious untoward event”.
Preliminary assessments by clinical pathologists showed that there was no clear connection between the baby’s condition and the atropine overdose.
The baby remained in critical condition at Queen Mary Hospital.
He was diagnosed with inflammation of the heart muscle and a respiratory syncytial virus infection, The Standard reported.
William Chui Chun-ming, chairman of the Society of Hospital Pharmacists of Hong Kong, said atropine is used to accelerate the heartbeat. An overdose of the drug may cause side effects such as aggravation of the patient’s fever, irregular hearbeat or even coma.
Chui said pharmacists stationed at the A&E department should double-check the dose of the drug before it is given to a patient.
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