Due to a system failure, an elderly woman was repeatedly given the wrong dose of heart medication. Photo/NZME
A system failure resulted in an elderly woman repeatedly receiving the wrong dose of heart medication, according to the Health and Disability Commission.
The elderly woman was admitted to West Harbor Gardens (WHG) in Auckland with cognitive impairment and a significant deterioration in her health which required hospital treatment, Deputy Commissioner Rose Wall said.
The woman suffered from several health problems, including a heart problem (atrial fibrillation), for which she was prescribed warfarin.
Warfarin is prescribed to help maintain a person’s blood clotting function within a therapeutic range.
Wall said the woman was given the wrong dose of warfarin six times by six WHG nurses. On another occasion, administration and documentation of the woman’s warfarin medication was incomplete.
Sunrise Healthcare Limited, which does business as West Harbor Gardens, has been found to have breached the Disability Services Consumer Code of Rights for failing to provide services with reasonable care and skill.
“The systems failures at WHG meant that the woman had been given incorrect doses of warfarin multiple times by a number of different clinical staff, and the errors were not identified until almost a year later. late following a family complaint,” Wall said.
“I cannot stress enough the potentially serious consequence for the woman not to receive the dose of warfarin that has been prescribed for her.”
Wall also criticized the facility’s response once the errors were identified, saying they weren’t documented in an incident report form, no investigation report was written, and actions corrective actions were not formally documented.
She recommended that WHG check for any medication errors, review the critical incident reporting policy and include a restorative approach to incident investigation, update the medication management policy and procedure, and issue a formal written apology to the wife and her family.
The institution has since changed a number of processes following the events of this case. This includes a new Community Practitioner policy for prescriptions and drug supply. It also requires that nurses update their medication skills and that regular checks are carried out to ensure that the dispensing of medications is properly documented.
Wall said she was pleased to see that WHG had completed extensive reviews of its policies and made changes to its processes that would lead to better service delivery for the residents in their care.