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Overdose of codeine administered to child (13HDC00213)
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Private hospital ~ Registered nurse ~ Medication error ~
Codeine ~ Overdose ~ Decimal point ~ Prescribing ~ Right
A 3-year-old boy was due to have a tonsillectomy and
adenoidectomy performed at a private hospital. His sister, aged
four years, was due to have the same procedures performed
The children's allocated admissions nurse was a registered nurse
(RN) who had six years' nursing experience, but had only recently
commenced employment at the private hospital and was working her
first shift alone following a four-week buddy period.
Prior to surgery an anaesthetist wrote prescriptions for the
children's pre-surgery medications. Pre-medications are
administered to patients prior to surgery to help prepare them for
surgery, and typically include sedative or pain relief medications.
In this case, the anaesthetist prescribed paracetamol and codeine.
The recommended adult dose for codeine is 30‒60mg, while the
recommended dose for the boy, based on his weight, was 8.5mg.
Before administering the pre-medications, the RN asked a senior
nurse to check the child's prescription with her, in accordance
with the private hospital's policy. The nurses both read the
prescription for codeine as 85mg. The nurses discussed the fact
that it was a large dose, but neither checked the prescription with
The RN administered the child 85mg of codeine orally. When she
checked the sister's prescription, which was for 8mg of codeine,
she realised that a mistake had been made. The child had his
stomach washed out, and the tonsillectomy and adenoidectomy was
performed as planned. He showed no evidence of codeine overdose
Despite having six years' experience as a registered nurse, the
RN administered more than the recommended adult dose of a commonly
prescribed analgesia to a three-year-old child. The RN's actions
were unacceptable and a breach of Right 4(1) of the Code.
The senior nurse's role, in acting as an independent checker,
was to provide a safeguard against errors such as this occurring.
The senior nurse failed in this regard and breached Right 4(1).
Adverse comment was made about the legibility of the
anaesthetist's prescription in this case, and the quality of her
documentation. Adverse comment was also made about the care
provided by the private hospital. Comment was made about the
child's postoperative care and the private hospital's Medicines
The child's prescription was altered retrospectively, but no
finding was made regarding who was responsible for this.