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Administration of drug to consumer with known allergy (14HDC00157)
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(14HDC00157, 9 June
Public hospital ~ District health board ~ Registrar ~
Registered nurse ~ Drug allergy ~ Administration error ~ Staff and
systems ~Right 4(1)
An 80-year-old woman was living independently at home with her
husband. She had previously experienced a severe adverse reaction
to the antibiotic trimethoprim, and wore a MedicAlert bracelet
showing this. The woman fell and suffered a fractured neck of
femur. She was admitted to a public hospital and underwent surgery.
One month later, the woman was transferred to another hospital for
a period of supportive rehabilitation care post surgery, prior to a
planned discharge to her home.
The admitting house officer took a full medical history and
documented that the woman had multiple drug allergies. The house
officer recorded in the progress notes: "NUMEROUS DRUG ALLERGIES →
see chart" and handwrote orange adverse reaction labels/stickers
and stuck one to each page of the drug chart. In particular, the
orange sticker stated: "Trimethoprim/Co-trimoxazole - toxic
Two days later, a registrar reviewed the woman and noted that
she had experienced difficulty in passing urine. A mid-stream urine
test suggested a urinary tract infection. The registrar prescribed
trimethoprim 1 x 300mg tablet to be given at night for five days.
The registrar stated that she was fatigued and, at the time she was
prescribing trimethoprim to the woman, she was focused on more than
one task. The registrar did not check the orange adverse reaction
sticker and, in failing to do so, acknowledged that she made a
That evening at 9pm, a registered nurse administered the woman
her first dose of trimethoprim 300mg. The nurse stated that
normally when a patient is charted a new medication she would check
that there were no allergies recorded on the chart, but in her
busyness she did not see the adverse reaction written on the
adverse reaction sticker, and instead placed too much reliance on
the fact that the woman would not be charted medications to which
she was allergic. The following morning, the woman was reviewed by
a different registrar, who identified that the woman had been given
trimethoprim and that she had an allergy to this drug. The
registrar stopped the trimethoprim and advised the nursing staff to
be on the lookout for signs suggesting an allergic reaction.
Within 24 hours the woman had peeling on her left inner thigh,
like a burn, and both of her legs had developed blisters. The woman
was readmitted to the public hospital with a life threatening skin
condition resulting from the allergic reaction to the trimethoprim.
The woman underwent surgery to remove damaged skin and dress her
extensive lesions and sadly died a few days later.
It was held that the registrar who prescribed the trimethoprim
breached Right 4(1) as it was her responsibility to take the
necessary steps to ensure that she prescribed medication to the
woman that was appropriate for her.
The nurse who administered the trimethoprim was also found to
have breached Right 4(1) as she had a number of opportunities to
identify the medication error by reading the clinical records and
drug chart, noting the MedicAlert bracelet, and talking with the
It was also held that the staff and the systems existing at the
DHB let the woman down. The DHB failed to provide the woman with
services with reasonable care and skill, and is directly
responsible for those failures. Adverse comment was also made about
suboptimal open disclosure and documentation at the DHB.