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Medication error contributing to patient’s death (03HDC14692)
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(03HDC14692, 14 October 2005)
Public hospital ~ District health board ~ Medication charts
~ Documentation systems ~ Admission procedures ~ Prescription and
administration of medications ~ Teamwork ~ Supervision ~ Patient
identification label ~ Morphine ~ Diabetic ~ Rights 4(1), 4(2),
The daughter of a 91-year-old rest home resident complained
about the care her mother received at a public hospital. The
elderly woman presented to the hospital's emergency department with
a suspected lower respiratory tract infection. At some time during
the clinical assessment or admission, a computer-generated patient
identification "bradma" label, on which was printed her name, date
of birth, sex, age, home address, admission date, GP, and unique
hospital identification number, was affixed to the top of a
completed medication chart intended for another patient.
The woman was admitted to a general medical ward and the
mislabelled drug chart was attached to her file. Over the next few
days she received several doses of morphine intended for the other
patient, and did not receive any of her own regular medications.
She deteriorated into a coma. Although the error was discovered and
the correct medications administered, her condition deteriorated
and she died as a result of pulmonary oedema secondary to acute
cardiac failure and pneumonia.
The labelling error could not be attributed to any individual
member of staff, although alert medical and nursing staff should
have detected it earlier.
It was held that the DHB did not have adequate systems in place
to prevent the mislabelling and incorrect filing of the drug chart,
and to ensure effective co-operation between individual members of
staff, in breach of Rights 4(1), 4(2), and 4(5). The fact that the
hospital systems were not sufficiently robust contributed to the
drug chart error remaining undetected, and the DHB breached Rights
4(1) and 4(5) in respect of these issues.
While the chart may have been accessible, had the doctors taken
steps to find it, it is clear that they believed it was for all
practical purposes "unavailable", since it was not immediately
present with the medical records during the round. The DHB now
requires that patients' notes and medication charts are present on
all ward rounds, and has provided doctors with swipe-card access to
dispensaries. It was held that in respect of these issues the DHB
breached Rights 4(1), 4(2) and 4(5).
The DHB was also responsible for the nurses' shortcomings in
consulting with the woman, her family, and other clinical staff,
and the failure to determine the clinical suitability of the
medications charted, because the systems and staff structures in
place were inadequate to ensure continuity and quality of care was
maintained and clinical reviews undertaken. In respect of these
issues, the DHB breached Rights 4(1), 4(2) and 4(5).