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Dispensing and administration of medication to rest home resident (13HDC01720)
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(13HDC01720, 29 June
Rest home ~ Nurse Manager/Registered Nurse ~ Pharmacy ~
Pharmacist ~ Dispensing error ~ Dementia ~ Rights 4(1),
A 77-year-old woman was admitted to a semi-secure aged care
facility from another rest home, due to her dementia and
Soon after the woman's admission, a pharmacist prepared the
woman's medications. The pharmacist incorrectly dispensed four
times the prescribed dose of risperidone, an antipsychotic which
can cause sleepiness. Although the pharmacy had five dispensary
staff members on duty that day, the pharmacist did not get anyone
to check her work, and did not notice the incorrect dose. The
pharmacist had made a number of dispensing errors prior to this
When the medication arrived at the rest home, medication
reconciliation was not undertaken by rest home staff. For over a
week the woman was administered the incorrect dose of risperidone.
During this time, the woman continued to wander into other
residents' rooms, was noted to be very sleepy, and was sometimes
unresponsive. Her vital signs were not checked, and no clinical
assessments (apart from at admission) are recorded. The Nurse
Manager/Registered Nurse felt that the woman's drowsiness was
caused by a urinary tract infection (UTI) and the antibiotics she
was taking for that.
There were instances where the woman's records did not indicate
whether medication was given and, if not, the reason for that. .
Antibiotics were commenced for the woman's suspected UTI, but there
was a gap of two days before a second dose was administered. The
risperidone dispensing error was subsequently discovered and
corrected. The woman was transferred to the public hospital.
It was held that the pharmacist selected the incorrect
medication dose and failed to check the medication against the
prescription, breaching Right 4(2). Adverse comment was made about
the pharmacist's management of the dispensing error once she was
notified of it.
It was also held that the pharmacy did not respond adequately to
the risk the pharmacist posed to consumers as a result of her
repeated dispensing errors. By failing to take appropriate steps to
prevent further dispensing errors, the pharmacy placed the woman at
risk of harm. Accordingly, the pharmacy breached Right 4(4).
The rest home had the ultimate responsibility to ensure that the
woman received care that was of an appropriate standard. There were
a number of concerns with the care provided to the woman at the
rest home, including staff reliance on the transfer documentation
from the previous rest home, as well as poor medication management,
medication reconciliation, and documentation. Furthermore,
inadequate staffing, in particular insufficient registered nurse
hours, contributed to the poor care provided to the woman.
Accordingly, the rest home breached Right 4(1). Adverse comment was
made about the failure by the rest home staff to undertake an
appropriate assessment of the woman's competence, meaning that
staff were not in a position to obtain appropriate informed consent
for her care and treatment.
The Nurse Manager/Registered Nurse failed to ensure that staff
at the rest home provided adequate care and treatment to the woman,
failed to maintain adequate care planning as the woman's condition
changed and her drowsiness increased, failed to react
appropriately to changes in the woman's condition, and did not
assess her or monitor her vital signs. The Nurse Manager/Registered
Nurse did not ensure that appropriate documentation was maintained
by the rest home staff, or that medications were being administered
safely in accordance with the rest home's medication policy.
Overall, the Nurse Manager/Registered Nurse failed to provide
services to the woman with reasonable care and skill and,
accordingly, breached Right 4(1).
Adverse comment was made about the Operational Manager's