They should have undergone a simple surgery to remove the cataract to the hospital of Spoleto and, instead, four elderly people lost an eye all on the same day. According to what Il Messaggero learns, there would have been an exchange of bottles during the preparatory phase of the operation. In this case, the patients were allegedly injected – clearly by mistake – with an 8.4% sodium bicarbonate solution with a Ph between 7 and 8.5 which had been inserted into the bottle holder of the phacoemulsifier (a particular surgical procedure) instead of saline for ophthalmic use. An investigation by the Umbrian Court of Auditors has been opened into the case involving a nurse and a nurse.
The facts
The episode dates back to a few years ago. The patients, one man and three women, all aged between 70 and 80, were due to undergo cataract removal at the San Matteo degli Infermi hospital in Spoleto. Generally it is an operation that is performed, when severe eye injuries are not detected, as in this case, with the technique of phacoemulsifiers. The procedure consists in the removal of the opaque lens by ultrasonic fragmentation after injection of a saline solution. The fact is that, at the end of the intervention, the elderly people lost sight in one eye. A fifth patient, also scheduled for surgery on the same day, was saved because someone noticed the bottle swap in time.
The error
According to what emerged during the accounting investigation, a nurse had stocked the pharmaceutical cabinet for the ophthalmologist’s operating room with bottles of medicine taken from the surgery storage area. Not finding the saline solution for ophthalmic use in the warehouse, he had looked for it in another warehouse. So sodium bicarbonate had appeared which, despite having a different name, had the exact same labeling as physiological.
The compensation
A case has been openedinvestigation of the Court of Auditors of Umbria which, after the compensation paid by the hospital to the patients, certified how much the two doctors involved in the investigation will have to return to the Region. The nurses, a nurse and a coordinator of the nursing area, have already received a disciplinary sanction: one day’s suspension and salary reduced from the working day. In the writ of summons, the accounting judiciary speaks of “brand and gross mistake – committed by the nurse – for inserting a bicarbonate solution in the bottle holder rod of the phacomulsifier as an infusion solution instead of the balanced saline solution for ophthalmic use“. As for the coordinator “the co-responsibility in the harmful event due to the poor organizational management of the drugs is serious – writes the Court – and of the principals of the operating room…, also with reference to the relative traceability, handling and proper placement“.