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Inappropriate prescription of narcotic medication (12HDC01608)
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(12HDC01608, 10 November
Public hospital ~ District health board ~ House officer ~
Registrar ~ Consultant ~ Renal impairment ~ Documentation ~ Rights
An elderly man with complex co-morbidities including chronic
renal impairment was admitted to hospital for the management of an
acutely ischaemic leg. The man underwent an angioplasty and the
man's pain was noted to have improved postoperatively. The man was
reviewed by the surgical registrar and the decision was made to
discharge the man home on either the Sunday or Monday.
The registrar reviewed the man on the Sunday morning and changed
his medication from fentanyl to Sevredol. The ward round book
records "discharge + script". The registrar did not document a
discharge management plan, any details of the decision to prescribe
Sevredol, or the plan with regard to monitoring and reporting the
man's Sevredol requirements.
Later that day, the on-call surgical house officer was contacted
by a nurse who requested that the house officer write a
prescription for antibiotics for the man so that he could be
discharged. The house officer prescribed an appropriate antibiotic
taking into account the man's renal impairment. As the house
officer was leaving the ward the nurse requested a prescription for
analgesia for the man. The house officer noted that the man had
been prescribed Sevredol earlier that day by the registrar, so
wrote a prescription for the same dose that had already been
prescribed. The house officer did not complete the discharge
The man was then discharged and returned home. He took his
medications as prescribed, including a total of five 10mg Sevredol
tablets. The following morning the man was found unconscious by his
daughter. He was later admitted to hospital and treated for opioid
toxicity. Sadly, the man died a short time later.
Adverse comment was made that the registrar failed to critically
assess the appropriateness of prescribing Sevredol to the man,
given that his pain was already well managed and he had renal
impairment. It was held that having made the decision to prescribe
such medication the registrar should then have proceeded with
caution. The registrar's failure to document a discharge plan and
the decision to prescribe Sevredol, and its monitoring
requirements, demonstrated a lack of caution that placed the man at
unnecessary risk of harm. Accordingly, the registrar was found to
have breached Right 4(4).
The house officer was not found to have breached the Code.
However, criticisms were made of aspects of the care the house
officer provided, in particular the failure to critically question
the prescription of Sevredol in a man who had renal impairment, and
the failure to complete any discharge documentation. The consultant
was found not to have breached the Code in light of the fact that
the consultant was not informed that the man had been prescribed
Sevredol, and there was no expectation that the consultant should
be involved in the man's discharge.
The DHB was found to have breached Right 4(1) for failing to
ensure that its staff provided services with reasonable care and
skill. Adverse comment was made about a retrospective change being
made to the man's medication chart.