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Trial dose of medication not administered in hospital (12HDC00599)
Download Trial dose of medication not administered in hospital (12HDC00599) (PDF 34Kb)
(12HDC00599, 25 September
Public hospital ~ District health board ~ Medication ~
Side effects ~ Trial dose ~ Communication ~ Provision of
information ~ Discharge ~ Rights 4(1), 4(5),
A 74-year-old man with a history of asthma and chronic
obstructive pulmonary disease was admitted to a public hospital
with a three-day history of shortness of breath, coughing and the
reoccurrence of an atrial flutter. He was transferred to another
public hospital the next day for a cardioversion procedure.
The procedure was successful and a consultant reviewed his care
the next morning. The consultant instructed that the man be given a
different type of medication as prophylaxis against atrial flutter.
The consultant was aware of the possible respiratory side effects
of the medication and intended that a trial dose be administered in
hospital. The clinical record for this consultation was completed
by a medical registrar and included the words "start one dose now".
There was no documentation in the medical notes as to the potential
risks of this medication and no written instructions to the nursing
staff setting out the necessity for a test dose or any required
observations. The man was not aware of the potential for an adverse
reaction or that a test dose was necessary.
The man was discharged home that morning without receiving the
prescribed first dose. The discharging doctor either failed to
notice, or did not question, the instruction in the notes. In
addition, the prescription was not given to the man and was
subsequently faxed to his local pharmacy.
The man took the first dose of the medication at home. He
suffered an acute exacerbation of his asthma and required emergency
treatment at the local medical centre.
As a result of communication failures between the prescribing
doctor and the nursing and medical teams, services were not
provided to the man with reasonable care and skill and accordingly
the DHB breached Right 4(1) of the Code. In addition, the man's
continuity of care was inadequate and the DHB therefore breached
Right 4(5) of the Code.
The man was not informed about the risks, benefits and need to
take a trial dose of the medication. This was information that a
reasonable person in the man's circumstances would expect to
receive. Provision of this information would have enabled him to be
a partner in his own treatment. By not giving the man this
information the DHB breached Right 6(1)(b) of the Code.
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