Appropriate systems for correct staff management of critically important medications vital for patient safety

This case highlights the importance of aged residential care facilities having appropriate systems in place to ensure that nursing staff administer critically important medications correctly, and for medication errors to be identified and followed up in a timely manner.

An elderly woman was admitted to an aged residential care facility due to a cognitive impairment and a significant deterioration in her health, which required hospital-level care. The woman had multiple medical conditions, including a heart condition (atrial fibrillation), for which she was prescribed warfarin.

Warfarin is an anticoagulant medication prescribed to maintain a person’s blood-clotting function within a therapeutic range. Blood tests are undertaken regularly to monitor patients who are prescribed warfarin, with the dose of warfarin adjusted in response to the results.

The woman was administered an incorrect dose of warfarin on six occasions by six nurses at the care home. On another occasion, the administration and documentation for the woman’s warfarin medication was incomplete.

Medication Management Policy and Procedures of the care home did not include recommended practice regarding quality and risk management of medication errors and open disclosure to the consumer, and in this instance her family/whānau.

Investigation of this complaint found that when the errors were identified, they were not documented in an incident report form, no investigation report was completed, and corrective actions were not documented formally. As such, the opportunity to identify the cause of the medication errors and implement remedial actions in a timely manner was lost.


The care home was found to be in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill.

The Deputy Commissioner was critical that systems failures at the care home meant that the woman was administered incorrect doses of warfarin on six occasions, and the errors were not identified until almost a year later following a complaint from the family.

The Deputy Commissioner also made adverse comment about the lack of open disclosure of the errors to the woman’s family.


HDC recommended that the care home:

  • Audit any medication errors (over a three-month period;
  • Review the Critical Incident Reporting policy and include a restorative approach to investigating incidents;
  • Review and update the Medication Management Policy and Procedures; and
  • Provide a formal written apology to the woman and her family.

Changes made

The care home made a number of changes following the events of this case. It now uses the electronic medication management system Medi-Map instead of paper-based signing sheets, it has reviewed its policies, it has issued a new Community Practitioner Policy for prescriptions and supply of medications, and it requires its nurses to update their medication competencies. In addition, regular checks are undertaken to ensure that the dispensing of medication is documented correctly.

Read the full decision here.