Asked distilled water for humidification of the ventilator gas for infants, a chemist at the Post Graduate Institute of Medical Education and Research (PGIMER) supplied a lethal chemical. It happened twice on different occasions in September last year but alert nurses at the Advanced Paediatrics Centre of the institute noticed both the times that it was formalin - a highly-toxic chemical - and not water and a major tragedy was averted.
Looking at the gravity of the issue, on March 26, the director of the PGIMER gave approval to refer the case to the drug committee of the institute and marked an inquiry to into the matter.
The chemical was supplied twice by Universal Chemists located in Nehru Hospital of the PGIMER in September last year. The incident was pointed out by Dr Praveen Kumar, head, neonatology unit of the PGIMER, in a letter written to the institute administration. He said the incident occurred on two separate occasions and both times presence of mind of staff nurses saved the babies from developing serious complications.
He said formalin is a laboratory chemical and it got no role to be kept and supplied by a chemist retailer. “If inhaled it can lead to serious respiratory complications and can even lead to the death of a patient,” Dr Kumar said in his letter.
Following the letter from neonatology unit head, the PGIMER administration marked an inquiry to the head of pharmacology department. In his inquiry report, which was submitted on November 22, pharmacology department head Dr A Chakrabarti found that the labels of both distilled water and formalin chemical were similar.
“It involves the Drug and Cosmetic Act, which is related to misplaced drug labeling and authorisation issues and supply of such item, inadvertently, might result in serious health consequences,” said Dr Chakrabarti in his report.
He said the matter requires thorough investigation.
Following that, the matter was discussed in a high-level meeting of the estate branch on March 12 and the PGIMER director gave approval to mark an inquiry to the drug committee on March 26.
However, the chemist, in an explanation to the PGIMER, said the boxes of distilled water received from the stockist had some bottles of formalin in the stock. The chemist is said to have even written to the manufacturer to change the label.