A single dose of Ativan given by mistake kills a septuagenarian

A septuagenarian lost his life in August 2020 after accidentally receiving a large and fatal dose of the drug Ativan at the CHSLD in Saint-Jean-sur-Richelieu, on a day when nearly half the staff disappeared amid an epidemic.

The name of the product on the bottle was not checked before Denis Putin was given what was supposed to be medicine for his heart failure, coroner Andre-H’s report reveals. Thandavino made it public last week.

The nurse took the wrong vial and instead administered 30 milligrams (mg) of Ativan intravenously to a 74-year-old man. A normal dose of this product is 1-2mg Register D^R Don’t jump.

Within an hour, Mr. Boot had vomiting and respiratory distress. He was rushed to a hospital center where he died the same evening.

At CHSLD in Saint-Jean-sur-Richelieu that day, the Human Resources Department attempted to replace the missing staff, but without success. Although normally two head nurses would have been on the floor, only one with 74 patients was “on the background of staff shortages. »

Besides, it should not have been within striking distance. Medication should always be kept in a locked container in the refrigerator, T notes^R Don’t jump.

Denis Putin’s ex-wife remembers how much the father of her two boys loved her new CHSLD “before the pandemic wiped it all out.”

“He was treated well. He had access to care, activities like bingo and he was well-rounded. I even heard him sing for the first time in his life,” Liz Grennan says with a lump in her throat.

“With the pandemic, everything fell apart,” she continues over the phone. Employees were driving. He never saw the same people. It was doubly smelly and there were dirty napkins in the hallway. Something has indeed changed. »

The death, described as violent by the coroner, is a reminder of the importance of having a law for patient-nurse ratios, believes Denis Grondin, president of the Union of Care Professionals of Montérégie-Centre.

“The heavier a nurse’s workload, the greater the risk of error. Putting patient limits on a nurse is the way out of that, so it doesn’t happen again,” he emphasizes.

According to him, having a nurse in his charge at CHSLD for a day shift with 74 patients is “problematic and dangerous. »

“Generally, when there are ratios that aren’t good, it goes to senior management,” he explains.

Nadon Health Group, which manages this private CHSLD, did not respond to our request for an interview.