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Prescription of medication to patient with an allergy (15HDC00100)

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Emergency department consultant ~ Emergency Department ~ Prescription ~ Allergies ~ Rights 4(1), 4(2), 6(1), 7(1)

A woman who had a suspected ankle fracture was referred to the emergency department (ED) by her general practitioner (GP) for further assessment. On the referral letter the GP noted that the woman was allergic, among other medications, to morphine.

On arrival at the ED the woman completed a patient admission form on which she documented under "any medical alerts or allergies?" that she was allergic to "morphine, codeine, penicillin, erythromycin".

The woman was triaged and then seen by the ED consultant. The consultant noted the woman's history and her current medications and requested an X-ray. It was later documented in the nursing notes that the woman was allergic to "penicillin, morphine, codeine, erythromycin".

The woman subsequently had an X-ray which was reviewed by the consultant. The consultant noted that there was no obvious fracture but queried a Lisfranc fracture and suggested a CT scan. The consultant discussed a referral to the orthopaedic team with the woman and then requested orthopaedic review. The consultant then prescribed the woman Sevredol, which is the controlled drug morphine sulphate in tablet form, and discharged her home. The consultant did not ask the woman whether she had any allergies, nor did he explain that Sevredol was a form of morphine. The consultant also did not document his management or discharge plan.

Following the woman's return home, but before she took the Sevredol, the woman's mother, a registered nurse, noted that the woman had been prescribed morphine. The woman's mother called the ED and then subsequently went into the ED and spoke to another ED doctor who apologised for the error and, after reviewing the woman's notes, dispensed alternative pain relief for her.

The consultant was found to have breached Right 4(1) for inappropriately prescribing Sevredol to someone who had a known and well documented allergy to that drug. The consultant also breached Right 6(1) by failing to explain that Sevredol is a form of morphine and by therefore failing to ensure that the woman was provided with information that a reasonable consumer, in that consumer's circumstances, would expect to receive. As a consequence, the woman was unable to give her informed consent for this aspect of the treatment, and the consultant breached Right 7(1).

The consultant also breached Right 4(2) for failing to document his management, a discharge plan and, in particular, his prescription of Sevredol.

The consultant's failures in this case were considered to be individual clinical errors, and the district health board was not found to be vicariously liable for the consultant's breaches of the Code.

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