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Storage and return of patient’s own medication at public hospital (14HDC00794)
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(14HDC00794, 10 February
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
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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