Medication Administration Error

The Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found a Registered Nurse (RN) and Counties Manukau District Health Board (now Te Whatu Ora Counties Manukau) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code).

The breach involves Right 4(1) which centres on the consumer’s right to have services provided with reasonable care and skill.

The case concerns the care provided to a woman in her fifties who was a regular haemodialysis patient at Middlemore Hospital (Te Whatu Ora Counties Manukau).

During the woman’s routine haemodialysis in 2019, a registered nurse (who was the woman’s primary nurse for that visit), made a medication error that led to an overdose of fentanyl (a controlled drug). The medication (naloxone) given to counteract the fentanyl caused the woman significant pain and distress.

The patient’s fentanyl medication was removed from the dispensing machine by the RN without being prepared and checked by a second RN. This is contrary to the requirement of Te Whatu Ora Counties Manukau’s policy. Later the RN picked up the fentanyl medication, mistaking it for another medication, and administered an incorrect dose to the woman. The RN immediately realised the error and reported it.

Dr Caldwell found the RN in breach of the Code for multiple issues, including failing to prepare the fentanyl immediately, incorrectly administering the fentanyl, not monitoring respiratory rate and providing insufficient documentation.

"Fentanyl is a strong opioid that requires careful preparation and administration owing to its potency," said Dr Caldwell. "The RN had a duty of care to the patient to prepare the fentanyl safely, in accordance with CMDHB’s Intravenous Opioid Protocol."

Dr Caldwell also noted insufficient documentation of the care provided by the RN, including failing to document the incorrect drug administration in the woman’s medication chart and failing to provide a timeline of the observations after the fentanyl overdose.

Dr Caldwell also found Te Whatu Ora breached Right 4(1) of the Code due to the practice of nursing staff on the dialysis unit to inappropriately remove medication from the dispensing machine before it was required.

Further, multiple staff did not adequately document the woman’s care and observations, and the woman’s pain was not assessed using an objective pain assessment tool.

Dr Caldwell made a number of recommendations for Te Whatu Ora Counties Manukau, including to:

- Provide a written apology to the woman.

- Undertake an audit of compliance by nursing staff with its opioid and controlled drug policies.

- Provide training and education to ensure clinical staff in the dialysis unit are aware of Te Whatu Ora Counties Manukau’s naloxone administration policy and standards for documentation.

Dr Caldwell recommended the RN provide a written apology to the woman and undertake training on documentation and safe administration of medication.

Since the complaint, Te Whatu Ora has made a number of changes including mandating that staff no longer remove medication from the dispensing machine before patients are physically in the unit, and for medication to be checked out as close to administration time as is practically possible.

The RN has also made changes including, undertaking the mandatory training for all Te Whatu Ora’s nursing staff and practising the "5 Rights" before administrating medication.

"I note that the registered nurse in question has made changes to his practice to, ‘ensure that it is safe, competent, professional’," Dr Caldwell said.

The full report of this case will be available on HDC’s website. Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.

More information for the media, including HDC’s naming policy and why we don’t comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

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