Nurse gave patient 10 times the correct dosage of medication on day he died
A distracted nurse who was unfamiliar with an elderly patient's medication gave him 10 times the prescribed amount just hours before his death.
The 73-year-old patient with a complex medical history was admitted to a hospital emergency department with shortness of breath, leg swelling, diarrhoea, vomiting and low blood pressure.
The location of the hospital was not disclosed in the just-published Health and Disability Commissioner's report and many details of the 2013 incident have been suppressed.
The patient was in hospital for a week and on day seven was assigned to the care of the registered nurse in question.
She was unfamiliar with the patient's dosage of metoprolol, a heart medication, and after reviewing the patient's medical chart believed the doctor must have put the decimal point in the wrong place.
The nurse noted the prescribed medication of 11.875mg of the medication daily but believed the doctor meant to write 118.75mg.
She said she had meant to check the dosage with a colleague but became distracted and returned to give the higher and incorrect amount.
By that afternoon, the man's blood pressure and overall health had deteriorated and while the nurse contacted medical staff for advice, she did not document what was passed on.
She also did not notify the ward nurse or see that the patient was reviewed by medical staff within 30 minutes and then every 30 minutes as required by hospital policy.
Later medical staff reviewed the medication chart and identified the incorrect dose of metoprolol.
The patient was transferred to the coronary care unit and attempts were made to lower his blood pressure but by midnight he had died.
A complaint was laid with the commissioner by the patient's daughter.
The commissioner found that by failing to give the correct dosage and by failing to notify the ward nurse, the nurse did not provide services with reasonable care or skill.
She was found in breach of the code of health and disability services consumers' rights and had failed to provide services in accordance with professional standards.
The commissioner recommended the nurse undertake further training on professional communication. She has provided a letter of apology to the man's family for her breach of the code, as recommended in the provisional opinion.
The commissioner also recommended that the Nursing Council of New Zealand consider undertaking a competence review of the nurse.