Elderly woman repeatedly given wrong dose of heart medicine in aged-care facility

A system failure has resulted in a elderly woman repeatedly being given the wrong dose of heart medication. Photo / NZME

A system failure has resulted in an elderly woman repeatedly being given the wrong dose of heart medication, the Health and Disability Commission says.

The elderly woman was admitted to West Harbour Gardens (WHG) in Auckland due to cognitive impairment and a significant deterioration in her health which required hospital-level care, Deputy Commissioner Rose Wall said.

The woman had multiple medical conditions including a heart condition (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 administered the wrong dose of warfarin on six occasions by six nurses at WHG. On another occasion the administration and documentation for the woman's warfarin medication were incomplete.

Rose Wall, Deputy Health and Disability Commissioner. Photo / Supplied.

Sunrise Healthcare Limited, which operates as West Harbour Gardens, was found in breach of the Code of Disability Services Consumers' Rights for failing to provide services with reasonable care and skill as a result.

"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," said Wall.

"I cannot overemphasise the potentially serious consequence of the woman not receiving her prescribed dosage of warfarin."

Wall also criticised the facility's response once the errors were identified, saying they were not documented in an incident report form, no investigation report was completed, and corrective actions were not documented formally.

She recommended that WHG audit any medication errors, review the Critical Incident Reporting policy and include a restorative approach to investigating incidents, update the Medication Management Policy and Procedure and provide a formal written apology to the woman and her family.

The facility has since changed a number of processes following the events of this case. This includes a new Community Practitioner Policy for prescriptions and supply of medications. It also now requires nurses to update their medication competencies and regular checks are undertaken to ensure the dispensing of medication is documented correctly.

Wall said she was pleased to see WHG had completed extensive reviews of its policies, and made changes to its processes which would lead to improved service delivery for residents in their care.