A registered nurse gave a seriously ill patient the wrong medication, then failed to report the error until two days later, by which time the patient was dead, a Health and Disability Commissioner's (HDC) report says.

Health and Disability Commissioner Anthony Hill referred the registered nurse to the director of proceedings, who has yet to decide whether to take a proceeding.

"There were a number of opportunities to prevent this medication error," Mr Hill said.

"The usual checks that should be undertaken before administering medication would have alerted (the nurse) to her error before the medication was administered."

By the time the nurse reported her error the 69-year-old patient's body had been home, with his family preparing for his funeral.

"Not only did this delay compromise the coronial inquiry, but it caused significant distress to the family when the police arrived to retrieve (the patient's) body for post mortem."

During the investigation, the nurse had advised the commissioner she was not working and did not intend to return to nursing practice.

The registered nurse said four registered nurses and a health care assistant had been working on the ward. She had a case load of six patients, and was in charge of the nursing team, responsible for allocating patients and duties, and overseeing the ward.

A request had been made for another person to "special" the patient involved in the case, but that "special" did not arrive.

The registered nurse had said she "pester(ed) the  roster office, but as often happened no one was available, the report said.

"I realise that I was wrong not to report the medication error immediately and while not trying to excuse my behaviour in not doing so I do want to explain that the shift had been very busy and stressful," the nurse told the commissioner.

"This was partly due to (the patient's) need for almost constant supervision, the fact that the "special" had not turned up and the need to wear isolation gear every time you saw him," she said.

"I would like to express my condolences and to apologise to (the patient's) family for anything that I may have to done to contribute to his death. My intention had been only to make his time on our ward as easy as possible for him."

Mr Hill said he did not accept the registered nurse's workload on the shift was excessive, and her workload did not excuse her actions.

MEDICATION MIX-UP

The HDC report said the patient was admitted to hospital on a Saturday in late 2010 with severe chest pain. He was diagnosed with a heart attack, severe anaemia, previously undiagnosed thrombocytopenia (low blood platelet count and an increased risk of bleeding) and acute myeloid leukaemia. On the Sunday, the man, who was acutely delirious and refusing care, was transferred to a side room in the cardiac/medical ward for symptom management.

The man’s condition deteriorated. On Monday, the registered nurse did not recognise the significance of the man’s deterioration or seek a medical review.

She obtained the man’s prescribed medication using the hospital’s automated medication dispensing system.

She also inadvertently attached the man’s medication administration sheet to the file of another patient. As a result, she mistakenly believed that medications listed on the other patient’s file had been prescribed for the man.

As those additional medications were not on the man’s profile on the automated dispensing system, the registered nurse overrode the system to obtain them. She decided to withhold one of the drugs, and subsequently administered three of the other patient’s medications, including cardiac drug sotalol, to the man.

Soon after, the registered nurse realised that she had given the man another patient’s medication. She did not report the error to the duty manager, or ask for the man to be assessed by a doctor. She looked up the additional medications in a pharmacy reference book and, finding that they were cardiac drugs, was reassured and decided that the man was not at risk of harm.

Not long after the man had been given those medications, he became short of breath. He died on Monday evening.

Mr Hill found the registered nurse breached the Code of Health and Disability Services Consumers' Rights, while the district health board did not breach the code.

The regional forensic pathologist had said the patient should not have been administered sotalol. Sotalol was a beta blocker and could improve cardiac conduction, but could also slow the heart through its negative action on the heart rate.

- © Fairfax NZ News