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Failure to report medication error (06HDC10115)

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(06HDC10115, 20 December 2006)

Health care assistant ~ Rest home ~ Dementia unit ~ Medication error ~ Incident report ~ Rights 4(1), 6(1)

A rest home dismissed a health care assistant for breaching its policy on administration of medication, and failing to report the incident, document the error, or inform the EPOA.

A health care assistant at the rest home administered a resident's 5pm medications at midday. The male resident was a particularly challenging dementia sufferer, and the health care assistant decided that, as she had made the error, she would "trial" this way of giving the medication, because the man was very active toward the end of the day. She said that the error occurred by accident.

When the evening staff came on duty she told them what had happened and asked them to give the man his midday medication at 5pm as an experiment. The health care assistants reported the matter to the on-site manager and, after an investigation, the health care assistant was dismissed.

It was held that the health care assistant failed to provide the man with an appropriate standard of care, breaching Right 4(1). It was also held that she did not take the necessary steps to ensure that the matter was brought to the attention of the man's family. No information about the medication error was passed on to the man, his wife, or his daughter, who was his enduring power of attorney. Accordingly, the health care assistant breached Right 6(1).  The matter was referred to the Director of Proceedings.

The rest home was held not to be vicariously liable for the health care assistant's breaches of the Code.

The Director of Proceedings filed a claim in the Human Rights Review Tribunal of alleging breaches of Right 4 of the Code.  The Tribunal found that the health care assistant did not deliberately alter the resident's medication, but that having made a mistake, she then decided to experiment and she failed to report the medication error.  The Tribunal therefore declared that there was a breach of Right 4(2) in failing to comply with relevant standards and 4(5) in failing to co-operate with other providers to ensure quality and continuity of services.

Link to Human Rights Review Tribunal decision:


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