Deaths caused by Tragic Error in Dosage of an Antifungal

Submitted by Aspergillus Administrator on 14 December 2010

Paul Richards was undergoing treatment for a fungal infection at Birmingham Heartlands Hospital in UK and was receiving one of the more recent formulations of Amphotericin, an antifungal that has been in use for many years. The new formulations (Ambisome and Abelcet) are much less toxic than the original formulation (Fungizone) and as such are often given in much higher doses, 3-5mg per kg of patient weight. Fungizone has a maximum dose of 1.25mg per kg.

In this incident an inexperienced doctor who was new to the hospital had apparently been instructed to administer the patient his antifungal medication. The information presented on the patient’s chart led the doctor to understand that they were to give Fungizone when in fact the intended drug was one of the more modern formulations. Presumably the chart gave the dose as 5mg/kg.
More established staff members understood what was required but this doctor was new and did not come to the same conclusion. The confusion led to Paul Richards and another patient being given Fungizone at 5mg/kg, both of whom subsequently died.

This tragic story illustrates the consequence of a series of small errors and contributing factors adding up to a huge error: including:

1. The doctor was new and was not familiar with the convention on that ward
2. Senior nursing staff failed to notice the error or inform the doctor of the convention
3. The doctor failed to read the notes supplied with the drug that warned of the maximum safe dose
4. Labelling of the chart was inaccurate

 The article in the British Medical Journal made the following points:

In a report on patient safety alerts published last August, the charity Action against Medical Accidents (AvMA), said an alert in March 2007, Promoting Safer Use of Injectable Medicines, might have saved Mr Richards’s life but 104 trusts had still not implemented it nearly two years after the deadline set.

After his death the National Patient Safety Agency issued a rapid response alert on the safer use of amphotericin to all NHS trusts in September 2007. But AvMA research published in February 2010 found that 10 NHS trusts had still not implemented it.