Systems Failures Result In An Elderly Woman Being Repeatedly Administered Incorrect Doses Of Warfarin

The importance of aged residential care facilities having
appropriate systems in place to ensure nursing staff
administer critically important medications correctly, and
for medication errors to be identified and followed up in a
timely manner, was highlighted in a decision published by
Deputy Commissioner, Rose Wall.

In her decision, Ms
Wall found Sunrise Healthcare Limited (trading as West
Harbour Gardens) in breach of the Code of Disability
Services Consumers’ Rights (the Code) for failing to
provide services with reasonable care and skill.

An
elderly woman was admitted to West Harbour Gardens (WHG) 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 regularly
undertaken to monitor patients who are prescribed warfarin,
with the dose of warfarin adjusted in response to the
results. The woman was administered the incorrect dose of
warfarin on six occasions by six nurses at WHG. On another
occasion the administration and documentation for the
woman’s warfarin medication was incomplete.

Ms Wall
noted that “Sunrise Healthcare’s duty to provide services
to the woman with reasonable care and skill included
responsibility for the actions of its staff at WHG. It also
has a duty to comply with the New Zealand Health and
Disability Services (Core) Standards.”

“Systems
failures at WHG meant the woman was administered incorrect
doses of warfarin on a number of occasions by a number of
different clinical staff, and the errors were not identified
until almost a year later following a complaint from the
family.

“I cannot over-emphasise the potentially
serious consequence of the woman not receiving her
prescribed dosage of warfarin,” said Ms Wall.

Ms Wall
was also critical that WHG’s Medication Management Policy
and Procedures 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.

“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,” said Ms
Wall.

Ms Wall recommended Sunrise Healthcare audit any
medication errors at WHG (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.

WHG has made a number of changes following the
events of this case. They have started using the electronic
medication management system, Medi-Map instead of
paper-based signing sheets, they have reviewed their
policies, and issued a new Community Practitioner Policy for
prescriptions and supply of medications, and they have
required their nurses to update their medication
competencies. In addition regular checks are undertaken to
ensure the dispensing of medication is documented
correctly.

“I am pleased to see WHG has completed
extensive reviews of their policies, and made the changes to
its processes which will lead to improved service delivery
for residents in their care,” says Ms
Wall.

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