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Elderly woman administered another resident’s medication (14HDC00823)

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(14HDC00823, 4 December 2015)

Registered nurse ~ Healthcare assistant ~ Caregiver ~ Rest home ~ Supervision ~ On-call arrangements ~ Medication error ~ Medication administration ~ Incident reporting ~ After-hours care ~ Rights 4(1), 4(2)

A 96-year-old rest home resident died following the administration of another resident's medication. The woman had a history of high blood pressure (hypertension) however, at the time of these events she was not hypertensive.

On the day of the error, a caregiver began the medication round at 8am. The caregiver picked up the medications for the woman, and those for another resident. The caregiver was then distracted by a further resident. She aided the resident, and then returned to the drug trolley. The caregiver took what she thought were the woman's medications, but instead administered medications that were prescribed for the other resident. Those included two medications used to treat high blood pressure.

When the caregiver returned to the drug trolley she realised her error. She gave the other resident his medications from his blister pack for the next day and then completed her medication round. At 9.12am she telephoned the on-call registered nurse (RN), and advised her of the error. The on-call RN was working at another residential care facility while on call for this facility.

The on-call RN advised the caregiver to monitor the woman. The caregiver checked her every 20 minutes or so by asking whether she was alright, checking her breathing, and touching her head to see if she had a temperature. Shortly before 10am, the woman became unresponsive. The caregiver called the on-call RN, and it was agreed that the caregiver would call another RN who worked at the facility, but who was off duty at the time, to assist her.

The other RN went to the facility and found the woman semi-conscious. She placed the woman in the recovery position and called an ambulance. The woman was taken to the Emergency Department at the local public hospital, where she later died. The Coroner found that the direct cause of death was "sudden death following ingestion of [medications used to treat high blood pressure]".

It was held that the caregiver failed to follow safe medication administration practice, and waited approximately one hour before contacting the on-call registered nurse after identifying that she had administered another resident's medication to the woman. The caregiver did not provide services to the woman with reasonable care and skill and, accordingly, breached Right 4(1).

The on-call RN failed to give adequate instructions to the caregiver with regard to monitoring the woman, and failed to ensure the ongoing monitoring of the health status of the woman. The on-call RN did not comply with professional standards, breaching Right 4(2).

The on-call RN agreed to be on call at the facility while working at another residential care facility and failed to ensure she had accurate information about the woman's medical history and her current medications. Furthermore, she assumed the medication error had just occurred when she was informed of it, and failed to act with sufficient urgency and seek appropriate medical attention. The on-call RN failed to provide services to the woman with reasonable care and skill and, accordingly, breached Right 4(1).

Adverse comment was made regarding the facility's management of on-call arrangements and its processes and systems for after-hours support. 

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