An 82-year-old suspected stroke victim at Masterton Hospital died after 'a fatal error' resulted in him being prescribed incorrect medication.
The Health and Disability Commissioner's report found the man had been prescribed tenecteplase instead of alteplase.
After observing the man and undertaking a CT head scan a medical consultant at Masterton Hospital instructed a house surgeon to start thrombolysis clot breakdown treatment.
The wrong medication was administered because of a communication breakdown between a Masterton house surgeon and a medical registrar working in 'a tertiary hospital' emergency department.
Tenecteplase is commonly used for the treatment of heart attack patients, not stroke, victims.
The report found the Masterton house surgeon was confused as to whether tenecteplase was the correct drug to use.
Instead of consulting a Masterton Hospital consultant he (the house surgeon) consulted the medical registrar working at a 'tertiary hospital.'
''She (the medical registrar) called the house surgeon back 10 minutes later and told him that tenecteplase was the medication they used (at the tertiary hospital).''
The Masterton Hospital house surgeon then prescribed tenecteplase.
''The uncertainty in the protocol as to which drug to use resulted in a series of actions - all 'small holes' in the provision of care - which lined up with disastrous results.
''The house surgeon was informed that tenecteplase was the only drug available in the (Masterton) ED.''
Concerned that the packaging indicated that the dosage in the protocol was higher than the manufacturer's instructions the house surgeon sought advice.
''He called the tertiary hospital, because it was their protocol. He did not contact the (Masterton Hospital) consultant at his own hospital as he was expected to do.''
The report concluded the deceased's right to have services provided with reasonable care and skill had been breached.
- © Fairfax NZ News
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