EDMONTON - Four patients at the Royal Alexandra Hospital were poisoned last Friday with peracetic acid and hydrogen peroxide, after the two disinfectants were accidentally released into their dialysis machines.

An employee of Atek Water Systems, an Edmonton company that worked on contract for AHS, mistakenly opened the wrong valve, and mixed caustic bleaching agents into the water that was being used as part of the dialysis process.

Since then, one patient has died, although AHS won’t link the death directly to the incident. Three other people are in hospital. One patient, released earlier, was admitted for observation.

Events like this naturally unnerve us. As vulnerable hospital patients, we put ourselves into the hands of experts and trust they have the ability to care for us. When an error like this happens, it shakes confidence in the system.

Yet at the same time, hospital staff work under unique pressure. If I hit the wrong button on my computer, I might accidentally send out an embarrassing tweet, but no one will die. I can’t imagine the stress of knowing that one mistake, one moment of confusion or inattention, could be fatal to those in my care.

That is why we need a complete investigation here: not to scapegoat one Atek employee, but to see where the system failed.

At the request of the dead patient’s family, there was no autopsy. The medical examiner’s office was never given access to body. The medical examiner will investigate, but will largely review the hospital’s own findings. Alberta Justice won’t decide whether to schedule a fatality inquiry until those investigations are complete.

Wilf Bullerkist, Atek’s general manager, says the company’s safety officer is also doing an investigation.

“We still have more questions than answers,” Bullerkist says.

Indeed we do.

Exactly what training did this Atek worker have? Who at the Royal Alex was responsible for his or her supervision? Why was the position contracted out to a private company in the first place?

But here’s the more troubling question. Why was the Royal Alexandra using a dialysis protocol that seems to have had no fail-safe? Why was the system set up in such a way that turning one wrong valve could be deadly?

While this might seem like an accident, it’s not the first of its kind.

In 2007, a 66-year-old woman in Hong Kong died, after her dialysis water was inadvertently contaminated with a bleaching solution of sodium hypochlorite.

In 2008, a 71-year-old woman in Muskegon County, Mich., died after her dialysis fluid was contaminated with peracetic acid and hydrogen peroxide.

In 2012, seven patients in the St. Louis, Mo., area were hospitalized, after their dialysis water was contaminated with chlorine bleach, which had been used a disinfectant. The hospital called it a one-time human error.

That same year, Kimberly Saenz, an LPN from Lufkin, Tex., was sentenced to life in prison for the murder of five dialysis patients who died after their dialysis fluid was contaminated with chlorine bleach. The defence had argued sloppy procedures at the clinic were to blame.

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