The Deputy Health and Disability Commissioner Dr Vanessa
Caldwell has found a Registered Nurse (RN) and Counties
Manukau District Health Board (now Te Whatu Ora Counties
Manukau) in breach of the Code of Health and Disability
Services Consumers’ Rights (the Code).
The breach
involves Right 4(1) which centres on the consumer’s right
to have services provided with reasonable care and
skill.
The case concerns the care provided to a woman
in her fifties who was a regular haemodialysis patient at
Middlemore Hospital (Te Whatu Ora Counties
Manukau).
During the woman’s routine haemodialysis
in 2019, a registered nurse (who was the woman’s primary
nurse for that visit), made a medication error that led to
an overdose of fentanyl (a controlled drug). The medication
(naloxone) given to counteract the fentanyl caused the woman
significant pain and distress.
The patient’s
fentanyl medication was removed from the dispensing machine
by the RN without being prepared and checked by a second RN.
This is contrary to the requirement of Te Whatu Ora Counties
Manukau’s policy. Later the RN picked up the fentanyl
medication, mistaking it for another medication, and
administered an incorrect dose to the woman. The RN
immediately realised the error and reported it.
Dr
Caldwell found the RN in breach of the Code for multiple
issues, including failing to prepare the fentanyl
immediately, incorrectly administering the fentanyl, not
monitoring respiratory rate and providing insufficient
documentation.
“Fentanyl is a strong opioid that
requires careful preparation and administration owing to its
potency,” said Dr Caldwell. “The RN had a duty of care to
the patient to prepare the fentanyl safely, in accordance
with CMDHB’s Intravenous Opioid Protocol.”
Dr
Caldwell also noted insufficient documentation of the care
provided by the RN, including failing to document the
incorrect drug administration in the woman’s medication
chart and failing to provide a timeline of the observations
after the fentanyl overdose.
Dr Caldwell also found Te
Whatu Ora breached Right 4(1) of the Code due to the
practice of nursing staff on the dialysis unit to
inappropriately remove medication from the dispensing
machine before it was required.
Further, multiple
staff did not adequately document the woman’s care and
observations, and the woman’s pain was not assessed using
an objective pain assessment tool.
Dr Caldwell made a
number of recommendations for Te Whatu Ora Counties Manukau,
including to:
– Provide a written apology to the
woman.
– Undertake an audit of compliance by nursing
staff with its opioid and controlled drug policies.
–
Provide training and education to ensure clinical staff in
the dialysis unit are aware of Te Whatu Ora Counties
Manukau’s naloxone administration policy and standards for
documentation.
Dr Caldwell recommended the RN provide
a written apology to the woman and undertake training on
documentation and safe administration of
medication.
Since the complaint, Te Whatu Ora has made
a number of changes including mandating that staff no longer
remove medication from the dispensing machine before
patients are physically in the unit, and for medication to
be checked out as close to administration time as is
practically possible.
The RN has also made changes
including, undertaking the mandatory training for all Te
Whatu Ora’s nursing staff and practising the “5 Rights”
before administrating medication.
“I note that the
registered nurse in question has made changes to his
practice to, ‘ensure that it is safe, competent,
professional’,” Dr Caldwell said.
The
full report of this case will be available on HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.
The
Commissioner will usually name providers and public
hospitals found in breach of the Code, unless it would not
be in the public interest, or would unfairly compromise the
privacy interests of an individual provider or a
consumer.
More information for the media, including
HDC’s naming policy and why we don’t comment on
complaints, can be found on our website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
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