Commissioner highlights medication error

Commissioner highlights medication error at Palmerston North Hospital

Systems failings have been blamed for a serious medication error which led to an elderly patient receiving five doses of another patient’s morphine at Palmerston North Hospital in April 2002.

The Health and Disability Commissioner, Ron Paterson, has released the findings of his investigation into a complaint about the care of 91-year-old Eileen Anderson.

Mrs Anderson was given slow-release morphine and other incorrect drugs after her name sticker was mistakenly placed on another patient’s drug chart. The mix-up was not detected for four days, and Mrs Anderson died two weeks later. Once the error was detected, her condition initially improved but she ultimately succumbed to a chest infection and heart failure.

In his report, Mr Paterson criticises the systems that led to the medication error.

He says: “Palmerston North Hospital’s systems allowed the care of an elderly patient to be compromised by mistakes and a lack of co-ordination. … Staff shortages in nursing, medical and clinical pharmacy roles made the overall environment unsafe.”

Mr Paterson visited Palmerston North Hospital on Tuesday 1 November, and met with medical and nursing staff, and MidCentral District Health Board management.

Following the visit, he said, “I am reassured that my and the Coroner’s recommendations have been implemented, and that there are now safeguards in place to prevent a similar tragedy.”

However, he urged other hospitals to look at their own systems to see if they need to make changes to prevent similar failings.

“It is important that lessons are learned from this case, not only by those involved … but by hospital staff, management, and Boards throughout New Zealand.”

Key facts from the report

Mrs Eileen Anderson, a bright and alert 91-year-old, was referred by her GP to Palmerston North Hospital with a suspected respiratory infection. She was assessed in the Emergency Department on 5 April 2002. Her name sticker was mistakenly placed on another patient’s drug chart. Mrs Anderson was admitted to a hospital ward and received the wrong drugs (including morphine) for 4 days before the error was detected. She did not receive her regular medicines during this time. Mrs Anderson became more and more drowsy and disoriented. Even when the error was detected, no one told Mrs Anderson’s family for 3 days. Mrs Anderson died 2 weeks later. The Coroner found that she might well have recovered had she received the correct medication.

Commissioner findings

• MidCentral District Health Board did not have adequate systems in place to prevent the drug chart mix-up. • There was no proper nursing handover when Mrs Anderson was transferred from ED to a hospital ward. • The hospital was short-staffed and frequent changes of staff meant that patient care was not properly co-ordinated. • There was a lack of supervision and monitoring of junior medical staff. • Mrs Anderson’s family should have been promptly informed when the medication error was detected. • As a result of its failures of care and co-ordination, MidCentral District Health Board breached the Code of Health and Disability Services Consumers’ Rights.

Key Recommendations

• The report to be circulated for orientation and training purposes at every level within Palmerston North Hospital. • The hospital must provide documentary evidence of its current policies and practices relating to:

1. Storage and labelling of patient records in the Emergency Department. 2. Medical and nursing staff arrangements in the Internal Medicine Line. 3. Incident reporting, including the reporting, review and audit of medication errors. 4. The implementation and review of “Not for Resuscitation” orders.

• It must also confirm that policies are in place for the involvement of nursing staff in ward rounds, home wards, regular audit and assessment of the content and accuracy of patient records, and regular audit of staff compliance with internal and external policies, guidelines and standards.

A copy of the report has been sent to the Minister of Health, the Director-General of Health, the Medical Council of New Zealand, the Nursing Council of New Zealand, the Royal Australasian College of Physicians, the Accident Compensation Corporation, the Palmerston North Coroner, the Quality Use of Medicines Group of DHBNZ, and Mrs Anderson’s former GP.

A copy of the report will be posted on the Health and Disability Commissioner’s website (www.hdc.org.nz opinion 03HDC14692) on Thursday 3 November.

Background information The Code of Health and Disability Services Consumers’ Rights is a regulation under the Health and Disability Commissioner Act 1994. It confers a number of rights on all consumers of health and disability services in New Zealand, and places corresponding obligations on the providers of those services, including hospitals.

At the end of an investigation, the Commissioner reports his findings to the parties, notifies the relevant registration authority (in this case the Medical Council) and professional College (in this case the Royal Australasian College of Physicians), makes recommendations, and publicises any relevant lessons.

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