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Storage and return of patient’s own medication at public hospital (14HDC00794)

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(14HDC00794, 10 February 2016)

District health board ~ Public hospital ~ Registered nurse ~ Medication error ~ Right 4(1)

An elderly woman was admitted to a public hospital. The woman brought her personal medications with her. During her admission, the woman's medications were kept in the Medication Room in an unlabelled bag and placed in a container labelled with her name and room number.

Following treatment, the woman was discharged. A registered nurse (RN) was responsible for the woman's discharge. The woman's son asked the RN for the medications his mother had taken to hospital to be returned to her. The RN went to the Medication Room and took the unlabelled bag from the container labelled with the woman's name and room number.

The RN did not check that the bag contained the woman's medications. The bag contained both the woman's medications and another patient's medications, which she took home, unaware that some were not her own. The woman took both sets of medications and became unwell, requiring a further hospital admission.

It was held that by having inadequate systems in place for the storage and return of medications brought in to hospital by patients, the district health board did not provide services with reasonable care and skill, and therefore breached Right 4(1).

Adverse comment was made about the RN's failure to check the medications she was returning to the woman.

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