| Woman died after doc presribed high dose of digoxin by mistake |
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Straits Times June 28, 2006 by Khushwant Singh & Leong Su-Lin A DOCTOR mistakenly prescribed too high a dose of heart medication - and her patient ended up dead about two months later. Clementi Polyclinic physician, Dr Diana Santos, admitted her error but said she discovered it soon afterwards, and called the pharmacy to correct the dosage for 88-year-old Madam Koh Ah Tow. However, the two pharmacy technicians who attended to Madam Koh denied that Dr Santos had talked to either of them about correcting the prescription, which was for four times her normal dosage of digoxin - a medicine that regulates the contraction of the heart. At the inquest into Madam Koh's death yesterday, State Coroner Tan Boon Heng said 'the evidence... suggests some aspects of medical mismanagement but due to the inconclusive nature of the evidence', he returned an open verdict. He said: 'It would not be appropriate at this inquiry to clearly allocate criminal responsibility to any individual.' The inquest heard that Madam Koh visited the polyclinic for her regular check-up on March 26 last year. Apart from inadvertently increasing the daily dosage of digoxin from the intended 0.0625mg to 0.25mg, Dr Santos also slightly increased Madam Koh's dosage of warfarin - an anti-coagulant that thins the blood. The coroner noted that the increased dosage of warfarin would have required Madam Koh to return to see the doctor one or two weeks later, but Dr Santos had scheduled a check-up two months later because the patient was old and not very mobile. In her evidence yesterday, Dr Santos, 36, agreed that one to two weeks should be the proper interval for a follow-up visit due to the increased warfarin. Madam Koh died nine weeks later on June 3. The cause of death was heart failure. Her condition had been complicated by pneumonia and chronic kidney failure. Heart expert B.A. Johan of the National Heart Centre had informed the coroner that the excessive digoxin could have contributed to Madam Koh's heart failure. Madam Koh's son, Mr Lian Teck Kah, said yesterday that family members had asked the pharmacist why the medication had been changed and the pharmacist just said that that was what the doctor had prescribed. 'I was angry at first when I found out about the mistake but after a while, I thought there's no point because she was quite old,' the 58-year-old retiree said in Mandarin. 'My mother is already dead. I don't want to harm the doctor. The doctor's quite young; she made a mistake, let her think about it.' The family believes a communication problem might have contributed to the error. Mr Lian said his mother had, for some time, been seeing a doctor at the polyclinic who could speak Hokkien. But the doctor became pregnant and was no longer at the clinic, so his mother ended up seeing Dr Santos. He was annoyed because they had asked for a doctor who could communicate with his mother in Hokkien, or one who could speak Mandarin, which is what he and his wife speak. They were told they could not choose a doctor. They believe the mistake would not have occurred if they could have communicated with the doctor. The coroner noted that the polyclinic had implemented a new system to prevent similar errors. It now requires that amendments be made on a new prescription form, and not communicated by telephone. Comments (0)
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