Serious incident in healthcare – medication mix-up

During two cardiac surgeries at Karolinska University Hospital in Solna, medications were mistakenly interchanged, resulting in the patients’ hearts being unable to resume beating following completion of the procedures. Both patients remain in intensive care on extracorporeal life support and require heart transplantation.

Medication errors are a known patient safety risk, yet serious incidents continue to occur despite measures taken to prevent them. This indicates that risks and vulnerabilities remain in medication management. An investigation by the Swedish Accident Investigation Authority is therefore considered likely to contribute to reducing medication errors and improving patient safety.

As an independent body outside the healthcare system, the Swedish Accident Investigation Authority complements investigations conducted by healthcare providers themselves and the supervisory activities of other public authorities.


Previous SHK investigations in the healthcare sector.

Fatal incident in the Cardiac Intensive Care Unit N25 at Karolinska University Hospital in Solna (only in Swedish)

Serious incident in health care - delay of cancer treatment