A public hospital has apologised to the family of a critically ill patient who was mistakenly given mouthwash to drink instead of water while receiving treatment in intensive care.
The glass containing a chemical antiseptic was held to the patient’s mouth at Mayo University Hospital (MUH) by a consultant, and a quantity of the liquid was consumed before the mistake became apparent.
The incident on June 12th was the subject of a formal complaint, which prompted an internal investigation at the hospital.
The patient’s family were notified this week that the investigation had concluded and that new practices have been introduced to prevent similar incidents.
In a letter to the complainant, hospital management apologised for the incident in the intensive care unit (ICU), where the patients was “inadvertently given mouthwash to drink instead of water”.
It also noted the consultant had already apologised to the patient and his family.
A review by the hospital’s pharmacy department established the main ingredient in the mouthwash was chlorhexidine – a chemical antiseptic.
“Since this incident, new practices have been implemented to prevent a reoccurrence,” stated the letter signed by general manager Catherine Donohoe and associate clinical director Dr Fionnula Lavin.
“The Clinical Nurse Manager (CNM) in ICU and Pharmacy have implemented an oral mouth care guideline of one mouth care episode per single use pour of mouthwash. Any remaining mouthwash should be discarded,” they wrote.
“The learning from this incident will also be shared across the hospital. It is very unfortunate that this incident occurred, and we are sorry for the distress that this event caused.”
The original complaint stated the patient, who is in his 40s, had not consumed liquid by mouth for some time prior to the incident. He was dehydrated and therefore gulped the liquid that was handed to him by the doctor.
He began drooling and became distressed before vomiting shortly afterward. The patient suffered from pain, dehydration and fatigue as a result of the mistake, according to the complaint.
He had been admitted to ICU suffering from advanced liver disease. It is understood that he continues to receive treatment as an inpatient at MUH.