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Overdose of paracetamol to acutely ill child (02HDC08949)
Download Overdose of paracetamol to acutely ill child (02HDC08949) (PDF 154Kb)
(02HDC08949, 31 March 2005)
Nurse ~ Public hospital ~ Intensive care unit ~ District
health board ~ ICU consultants ~ ICU registrar ~ Registered nurses
~ Burns ~ Dispensing of medication ~ Documentation ~ Infection ~
Investigations ~ Monitoring ~ Handover ~ Communication ~ Incident
reporting ~ Continuity of care ~ Division of responsibilities ~
Vicarious liability ~ Rights 4(1), 4(2), 4(5), 10(6)
A three-year-old boy residing overseas received burns to 60-70%
of his body from boiling water. He was transferred to a public
hospital in New Zealand, where his burns were debrided three times
under general anaesthetic. He was cared for initially in the
hospital's intensive care unit (ICU) before being transferred to
the children's ward four days later. He was readmitted to ICU the
following day when he developed fluid resuscitation problems as a
result of diarrhoea. He developed renal and liver failure and died
the next day.
Retrospective analyses of the boy's blood revealed elevated ALT
results, which indicated that one of the nurses had administered
the incorrect dose of paracetamol. The Coroner concluded that this
was not the cause of the boy's death. However, administering the
incorrect dose, and repeatedly doing so, did not reflect services
administered with the requisite skill and care and did not meet
professional standards. This was a breach of Rights 4(1) and
4(2).
The test results indicated that a second nurse had not
administered an incorrect dose. However, in the course of
documenting her own administration of the drug, the second nurse
became aware of the possibility of the other nurse's error and did
not report the incident. This meant that the boy was not
specifically monitored for any consequential effects of the
overdose, nor could the overdose be explored as a contributing
cause when the child's health went into sudden, unexpected decline.
Her actions and omissions amounted to breaches of Rights 4(1), 4(2)
and 4(5).
The doctors involved were found not to have breached the Code as
the action taken in considering other diagnostic possibilities was
reasonable.
The DHB was held vicariously responsible for the first nurse's
breaches, as there were various measures it could have taken to
prevent the error or reduce its likelihood. The DHB was found
directly liable for failing to advise the boy's parents of the
existence of HDC and independent advocates. Staff had the
opportunity to do this at various meetings they had with the boy's
parents after his death, and their failure to do so breached Right
10(6).
The two nurses were referred to the Director of Proceedings, who
commenced proceedings in the Health Practitioners Disciplinary
Tribunal. A charge of professional misconduct was upheld in respect
of both nurses. The first nurse was censured, while the second
nurse was ordered to practise under supervision for six months
should she return to practise in New Zealand, and to pay costs of
$5,000.
Link to Health Practitioners Disciplinary Tribunal
decisions:
www.hpdt.org.nz/portals/0/nur0518dfindings.pdf
www.hpdt.org.nz/portals/0/nur0517dfindings.pdf