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Pain management and palliative care 13HDC01254)
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13HDC01254, 13 March
Private hospital ~ Clinical
manager ~ Registered nurse ~ Palliative care ~ Pain management ~
Incident reporting ~ Communication ~ Right 4(1)
A 74-year-old man had terminal prostate cancer and bowel cancer
with associated metastases. He was on medication for pain
management, required assistance with showering and dressing, and
used a walking frame.
The man was admitted to a private hospital for pain management
and palliative care, and remained there for 23 days. His
medications at admission included the controlled drugs OxyContin,
methadone and haloperidol.
During the man's admission there were a number of errors made
regarding his medication, including a failure to administer
methadone in accordance with his prescription, for six days, and
the administration of oral haloperidol for five days despite the
prescription having been discontinued. On multiple occasions staff
also failed to record the administration of his medications
The man was not informed about the medication errors, and there
was a 10-day delay in notifying his family of the haloperidol
errors. The man was transferred to another hospital where, sadly,
he died a short time later.
It was held that the staff consistently failed to adhere to
relevant policies, and to manage the man's pain and medication
adequately. As a result, staff made multiple errors in relation to
the ordering, storage and administration of the man's medication,
in particular his methadone and haloperidol. Despite the man
experiencing high levels of pain, there were multiple occasions on
which his pain assessment and management were suboptimal.
Furthermore, once the medication errors were identified, staff
failed to respond appropriately in documenting and notifying the
man of the errors. The hospital failed to ensure that the man
received care that was of an appropriate standard and complied with
the Code and, accordingly, breached Right 4(1).
The clinical manager failed to ensure that staff complied with
relevant policies and procedures, particularly in relation to pain
and medication management; she did not follow up to ensure that
corrective actions had been carried out following the
identification of the medication errors; she failed to inform the
man's family of the errors in a timely manner; and she did not act
in a timely manner in administering OxyNorm to the man. In
conclusion, it was found that the clinical manager failed to
provide services to the man with reasonable care and skill and,
accordingly, breached Right 4(1).
A registered nurse failed to ensure that adequate clinical
nursing assessments were undertaken when the man had high levels of
pain, and she did not supervise the actions of staff in relation to
medication management and clinical documentation. In conclusion, it
was found that the RN failed to provide services to the man with
reasonable care and skill and, accordingly, breached Right
It was recommended that the hospital management provide ongoing
training to all registered nurses with regard to its policies and
procedures, communication with residents and their families,
medication management, and professional standards regarding
documentation; conduct an audit with regard to the corrective
action plan; and disseminate the learnings from this investigation
to all its facilities nationwide. The hospital has provided a
written apology to the man's family.
It was recommended that the Nursing Council of New Zealand
consider competence reviews of both the clinical manager and the
registered nurse, and that both provide written apologies to the
man's family for the breaches of the Code.