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"Accidentally gave child medication reported as allergy"

About: Perth Children's Hospital / Emergency Department Perth Children's Hospital / Ward 3C - Surgical Short Stay Same Day Pre OP Same Day Post Op Recovery/PACU

(as a parent/guardian),

8 times - 8 times our child was given antibiotics thru their cannula while admitted in PCH. The red wrist band my child had to wear was to show all staff they had an allergy. They put this wrist band on my child when they entered the Emergency Department. When my child had pain relief or antibiotics they asked them their name, dob and what they were allergic to. They would say penicillin. If they were asleep, I understand one nurse would read my child's band and tell the other nurse their allergy. Not a single one of these 8 times did anyone pick up on the fact that they were injecting my child with penicillin, their reported allergy.

When a group of 6/7 surgeon staff stood in my child's room assessing them and their condition each day, they asked about my child's allergy and in the same meeting mentioned they were on antibiotics, again no one picked up on it despite all reading my child's chart.

This horrific error was not picked up until my child's discharge prescription was being filled. The staff member (I believe the pharmacist) came in to check on my child and was honest with my about what happened. I was horrified. Now thankfully my child seems to have grown out of their allergy as we didn't see any side effects unlike the last time they had it. My child's little body had copped so much illness already, even more symptoms and illnesses would have been horrible at best, life threatening at worst.

We don't understand how an error of this magnitude can happen, firstly by the original Dr who prescribed the medication, the pharmacist and each and every one of the medical staff who had my child in their care. How is there not a process in place that prevents it even being ordered for them when the allergy is on the system? We lost faith in the hospital last year when they missed the fact that our other child's broken arm needed correcting last year (to which my child suffered the consequences), we tried to understand it was a record breaking night for patients in the ER that night. But when we thought our child may have needed surgery we thought the Children's Hospital was the best and safest place for them. Sadly we have little faith left in the hospital and we feel that we need to question every decision, every plan, every injection into our child's body or every dismissal of our concerns. 

Thankfully my child is recovering at home, next time the child given the medication they are allergic to may not be. I urge all parents of children with allergies to micro manage their health care in the hospital, question everything because I feel the paid professionals that were responsible for the care of my child let them down in a horrible way.

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Responses

Response from Child and Adolescent Health Service - WA 2 years ago
Submitted on 23/09/2022 at 9:19 AM
Published on Care Opinion Australia at 9:20 AM


Dear plusqk97,

We are very sorry to hear of your recent experience during your child’s admission at Perth Children’s Hospital (PCH). We always strive to give the best care to children, however I acknowledge that on this occasion we may not have achieved this.

We can reassure you that PCH has policies and guidelines in place for medication administration. We regret that these may not have been followed during your child’s admission.

We will ensure that medication administration education and training with the staff is a priority to reinforce the safe practice expected.

We understand you have recently been in contact with the CAHS Consumer Engagement Team at PCH and we have received more information which will be investigated further. You will receive a direct response through this process.

Thank you for bringing this to our attention and if you wish to discuss this issue further, please call the CAHS Consumer Engagement Team on (08) 6456 0032, Monday to Friday 8:30am to 4:30pm.

Best wishes,

Co-Director Nursing

Child and Adolescent Health Service

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