Both nurses failed to identify the error, despite multiple further opportunities and red flags. Photo: 123RF
The health watchdog has found an elderly man died after being given the wrong dose of the wrong drug.
Deputy Health and Disability Commissioner Vanessa Caldwell said the man, in his 90s, was admitted to hospital in 2018 after a fall led to seizures.
During his treatment two registered nurses - one of them a senior - incorrectly prepared and administered 20 ampoules of the wrong medication. The mistake was only discovered halfway through the infusion.
The man lost consciousness and was moved to intensive care, but died three days later from pneumonia.
Both nurses failed to identify the error, despite multiple further opportunities and red flags, Caldwell said, and did not properly double-check the medication.
"In my view, the nurses failed to comply with the DHB's Checking IV Medication and Fluids - IV Manual by not checking adequately that they had the correct drug in the treatment room/pre-administration check."
She found them in breach of the Code of Health and Disability Services Consumers' Rights, which said patients must be provided services with care and skill, and in line with legal, professional, and ethical standards. They had also failed to comply with the New Zealand Nurses Organisation guidelines on the administration of medicines, Caldwell said.
She also criticised Te Whatu Ora for poor medication storage and unclear policies.
"Te Whatu Ora, as a healthcare provider, is obligated to provide care in accordance with the Code, and to support its staff adequately with policies and procedures," she said.
One of the nurses had since done further training and apologised to the man's family. The deputy commissioner recommended the nurse report back on any medication errors that had subsequently occurred and any further changes made to her practice.
The second nurse was no longer practising, but Caldwell recommended she also apologise.
Te Whatu Ora had audited the medication room, approached Te Tāhū Hauora (Health, Quality and Safety Commission) for advice on safe storage, and updated its policies.
The deputy commissioner further recommended it be audited for all medication errors over three months and evaluate its double-checking process.