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Medication errors in a dementia unit (05HDC18726)
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(05HDC18726, 27 September 2006)
Registered nurse ~ Aged-care hospital ~ Medication
management ~ Registered nurse duties ~ Rights 4(1), 4(2)
A woman complained about the care provided to her husband in a
private aged-care hospital. She complained that on two occasions
registered nurses administered another patient's medication to her
husband, who was suffering from dementia.
During an afternoon drug round, the complainant's husband was
given another patient's antipsychotic/anti-anxiety medication by an
agency registered nurse. She was distracted from her medication
round by an agitated patient. The nurse also gave him the other
patient's 4pm and 5pm medications together. The patient lost
consciousness 10-15 minutes later. An ambulance was called and he
was conveyed to the public hospital Emergency Department and
admitted overnight for monitoring. He was discharged back to the
private hospital the following day.
During the morning drug round three weeks later, the patient was
again given another patient's medication. The registered nurse who
administered the incorrect medication to him on this occasion had
been employed by the private hospital for three years. She was
serving breakfast and making toast at the same time as
administering medications. She notified senior nursing staff of the
error, started vital recordings, recorded the incident and arranged
for the patient to be transferred to the public hospital, where he
was monitored for six hours before returning to the private
hospital. The hospital staff were advised to keep him on bed rest
and observe him for the next 24 hours. He did not appear to suffer
any ill effects from the medication errors.
It was held that the agency registered nurse breached Rights
4(1) and 4(2) of the Code in relation to her two medication
The hospital registered nurse was also found to have breached
Rights 4(1) and 4(2) of the Code, for failing in her professional
responsibility to notify the organisation of the risks the
medication administration systems posed to staff and patients, and
for her medication error.
The hospital was found to have breached Right 4(1) and 4(2) of
the Code in relation to its medication administration practice.
This case highlights the importance of having a written protocol
in place to ensure safe methods of medication administration, and
that actual medication administration practice reflects the
policies and procedures.