Dear Colleagues
Further to my previous mailings about the need to standardise the use
of drug units in the UK using the Consensus recommendations, I would
like to bring to your attention a recent fatality due to a
misunderstanding directly related to the confiusion of units.
A case of paracetamol overdose occurred in which the interval between
the possible paracetamol overdose and the blood sampling was not known.
The concentration obtained was 2.29 mmol/L. the doctor who interpreted
the result used the 'mg/L' scale, which suggested that the value was
very low and not requiring action. The mmol/L scale was not used because
the value obtained was off this scale (which only goes up to 1.3
mmol/L). The patient eventually died.
This episode is further evidence that the status quo, with different
labs reporting in different units, is associated with avoidable clinical
risk. It adds further support that we must act now or else a solution
will be forced upon us. I sincerely hope that any waverers will be
convinced of the need by this case.
With best wishes
Julian
Julian H Barth MD FRCP FRCPath
Consultant in Chemical Pathology & Metabolic Medicine
Department of Clinical Biochemistry & Immunology
Leeds General Infirmary
Leeds LS1 3EX
tel 0113 392 3416
fax 0113 392 5174
Editor-in-Chief, Annals of Clinical Biochemistry,
journal http://www.ingentaconnect.com/content/rsm/acb
submissions http://mc.manuscriptcentral.com/acb
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