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Medication errors; communication with the family of a rest home resident (08HDC20820)

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(08HDC20820, 1 December 2010)

Rest home ~ Nurse manager ~ Medication errors ~ Falls ~ Dementia ~ Communication ~ No breach

The family of an elderly woman complained about the care provided to her while she was living in a rest home. She was a resident for nearly three years and, during this time, three medication errors occurred, two of which involved mistaken identity. The third involved the woman's medications being found loose in her room.

The woman had dementia and was known to wander. She was found outside the rest home complex on a number of occasions. She also had a number of falls.

It was held that the medication errors were caused by individual error. The rest home had appropriate policies, procedures and training to prevent such errors, and the care provided to the woman generally was of an appropriate standard.

Although there was no breach of the Code of Health and Disability Services Consumers' Rights, this case is a reminder of the importance of personal relationships. There was room for improvement in the communication between the nurse manager and the family in relation to both the second medication error and concerns about whether the rest home continued to be a safe and appropriate home for their mother.