On Monday this week, we reported that Ntungamo District leaders had started an investigation into an incident at Kajumbajumba Primary School in Kyafoora Parish, Rugarama North Sub-county, where health workers mistakenly administered the wrong drug to more than 100 pupils during a deworming exercise.
It is incomprehensible how a deworming drug could have been confused with an epilepsy drug. Drugs come with extensive labelling, which begs the question, could the personnel administering the drug read? Were the labels in a foreign language? As the teams go out to carry out programmes such as mass vaccination, are they adequately supervised? Was there a qualified health worker in charge? This district exercise would surely be flagged off by a senior health official, perhaps a doctor?
Investigations should also cover the storage of drugs for such exercises. If the wrong medication can escape the notice of officials to the extent of it being used undetected, what is to stop officials from releasing expired drugs from the stores and embarking on vaccination or any other such exercise?
According to the Practical Guidelines for Dispensing at Lower Level Health Centres 2014 (PGD) produced by the Ministry of Health, Pharmacy Division, the personnel dispensing drugs should check the dispensed medicine against the prescription and the stock containers used, which includes checking that the label is correct and all information is filled in.
While outlining what constitutes good dispensing practice, the guidelines state that when preparing the prescribed medicine, one must select the stock container (pack or tin) by reading the label properly and cross-checking the medicine’s name and strength with the prescription; one also ought to make sure the medicine has not expired. Dispensers should read the container label at least twice during this process.
Therefore, as Ntungamo District health office and hopefully, the Ministry of Health as a whole, investigate this incident of drug mix-up, one of the initial questions that ought to be dealt with is whether the dispensers of the problem drugs were qualified to carry out the function, if the drugs were labelled clearly to avoid confusion and what chain of custody and verification was in place before the drugs were dispensed?
Mass drug administration ought to be more closely supervised to avoid a repeat of such unfortunate incidents, but also to maintain community faith in vaccination and other government mass mobilisation efforts for preventive healthcare.