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Eye medicine turns out to be dental paste

  Wednesday, 15 l 12 l 2010 Source:  The Straits Times   
By: Judith Tan

Woman’s eyelids stuck together after pharmacy mistake

dental-pasteA HOUSEWIFE was prescribed a gel to soothe an eye irritation – but ended up being given dental adhesive paste instead. The mix-up by the pharmacy at National University Hospital (NUH) caused Madam Pang Har Tin’s eyelids to stick together. The 63-year-old was rushed to the accident and emergency department to have her right eye flushed out. She has since made a full recovery.  

NUH apologised in a statement yesterday, saying: “We are deeply sorry for Madam Pang Har Tin’s experience which resulted from our error. “Her well-being is our priority, and we have arranged for our eye specialist to review her on Wednesday. We will do our best to see through Madam Pang’s recovery.” 

Madam Pang first saw a doctor at NUH last Friday for a routine follow-up to several pre-existing eye conditions, including glaucoma. Procedures performed during the appointment left a corneal abrasion on Madam Pang’s eye. On Monday, she returned to the hospital to see another eye specialist. She was prescribed Solcoseryl 20% Eye Gel, which would have helped it to heal. 

However, the mistake at the pharmacy meant she took home a tube of Solcoseryl Dental Adhesive Paste, an ointment meant for the treatment of inflammation and wounds in the mouth. Madam Pang cannot read English, so she did not discover the mix-up until she applied the ointment that evening, then discovered she had trouble opening her eye. 

She was treated at the emergency department at NUH using a technique called eye irrigation, which involves using saline to flush out any foreign particles in the eye. Her son Austin Liow said yesterday: “This is a very severe mistake, especially for the elderly who might not be well educated or read English. They will not know that they have received the wrong medication.” The 35-year-old civil servant added: “We were lucky that the box indicated it was a dental paste. If it had just the substance name, we would not even have realised there was a mistake.” 

Dr Esther Fu, an ophthalmologist at Gleneagles Medical Centre, said: “While the chemical mixture Solcoseryl itself will not cause major side effects, how it affects the eye depends on factors such as the acidity of this dental preparation and other compounds added.” Dr Christopher Khng, an eye surgeon at Gleneagles, said: “The thick, gritty texture of the dental paste could worsen the corneal abrasion, opening more area to bacteria infection. In a worst-case scenario, this could lead to vision loss.” However, he added that such severe side effects were unlikely as a paste would probably cause the individual to tear, washing the substance out of the eye. 

Ms Christine Teng, vice-president of the Pharmaceutical Society of Singapore, said: “The main reason this error occurred is probably due to the products looking very alike, which led to the wrong product being packed and dispensed.” Guidelines from the Ministry of Health recommend that similar-looking medications be stored in separate places, and that caution stickers be placed on stock containers to alert staff to these lookalikes. It also recommends that information on medications with similar names be made available to staff. 

An NUH spokesman said: “The pharmacy staff involved have been counselled, and we have tightened our processes to minimise the risk of a similar error.”

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