A nurse at a Tokyo municipal hospital accidentally injected disinfectant into the intravenous drip of a patient instead of a substance meant to prevent blood clotting, killing the woman in February, police said Tuesday.

Police have launched a manslaughter investigation involving the nurse at Tokyo Metropolitan Hiroo Hospital, Shibuya Ward. Police also suspect hospital management oversight.

The patient, a 58-year-old homemaker from Urayasu, Chiba Prefecture, was suffering from rheumatoid arthritis and was hospitalized Feb. 8. She underwent an operation on the middle-finger joint of her left hand two days later.

She complained of an intense chest pain Feb. 11 upon receiving an intravenous drip shortly after 9 a.m. She died at around 10:45 a.m.

The hospital claims it initially thought the death was due to an illness unrelated to the operation, but later discovered the nurse who had prepared the intravenous drip had injected about 10 ml of the disinfectant chlorhexidine.

A doctor had ordered an injection of 100 ml of antibiotics and 10 ml of hepalin, an anticoagulant. It was later found that one nurse prepared the drip, while another had actually made the injections. Chlorhexidine is used to disinfect flesh wounds, but when ingested, the substance burdens the heart, sometimes causing death, doctors said.

An autopsy to investigate the cause of death was impossible because the woman’s body had already been cremated before police were notified 11 days later on Feb. 22.

Kiyoshi Okai, director of the hospital, told a press conference Tuesday afternoon that they did not deliberately wait to inform the police. “We originally thought the sudden change of the patient’s condition was caused by a heart disease,” Okai said.

“The accident should never have happened. I apologize deeply,” said Muneharu Mashiko, a director in the Hospital Management Division of the Tokyo Metropolitan Government’s Bureau of Public Health. “We want to pinpoint why this happened, and use this experience to improve hospital administration.”

Takeshi Kawakami, an expert on medical issues, said the training level of nurses rises year by year, but these incidents are also on the rise because of poor communication between nurses and doctors, the lack of a checking mechanism to catch these mistakes and because staff do not receive a moment’s rest in a hospital. The incident was a warning signal, he said. “This incident is due to carelessness on the part of the nurse, but a more fundamental solution is needed, such as reforming the training process and eliminating unnecessary treatment and tests,” he said.

Similar incidents have occurred in the past: in Hokkaido in 1990, Aomori Prefecture in 1995, Toyama Prefecture in 1996 and Osaka Prefecture in 1998.

In January this year, two male patients received the wrong operations during a mixup that occurred during a change in the nursing shift at Yokohama City University Hospital. Observers say such malpractice is only the tip of the iceberg and that most cases have been hushed up.

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