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Trial dose of medication not administered in hospital (12HDC00599)

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(12HDC00599, 25 September 2013)

Public hospital ~ District health board  ~ Medication ~ Side effects  ~ Trial dose ~ Communication ~ Provision of information ~ Discharge ~ Rights 4(1), 4(5), 6(1)(b)

A 74-year-old man with a history of asthma and chronic obstructive pulmonary disease was admitted to a public hospital with a three-day history of shortness of breath, coughing and the reoccurrence of an atrial flutter. He was transferred to another public hospital the next day for a cardioversion procedure.

The procedure was successful and a consultant reviewed his care the next morning. The consultant instructed that the man be given a different type of medication as prophylaxis against atrial flutter. The consultant was aware of the possible respiratory side effects of the medication and intended that a trial dose be administered in hospital. The clinical record for this consultation was completed by a medical registrar and included the words "start one dose now". There was no documentation in the medical notes as to the potential risks of this medication and no written instructions to the nursing staff setting out the necessity for a test dose or any required observations. The man was not aware of the potential for an adverse reaction or that a test dose was necessary.

The man was discharged home that morning without receiving the prescribed first dose. The discharging doctor either failed to notice, or did not question, the instruction in the notes. In addition, the prescription was not given to the man and was subsequently faxed to  his local pharmacy.

The man took the first dose of the medication at home. He suffered an acute exacerbation of his asthma and required emergency treatment at the local medical centre.

As a result of communication failures between the prescribing doctor and the nursing and medical teams, services were not provided to the man with reasonable care and skill and accordingly the DHB breached Right 4(1) of the Code. In addition, the man's continuity of care was inadequate and the DHB therefore breached Right 4(5) of the Code.

The man was not informed about the risks, benefits and need to take a trial dose of the medication. This was information that a reasonable person in the man's circumstances would expect to receive. Provision of this information would have enabled him to be a partner in his own treatment. By not giving the man this information the DHB breached Right 6(1)(b) of the Code.

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