Elderly woman with dementia given incorrect dose of medication

The women was given four times her proper dosage. Photo / iStock.

An elderly woman with dementia was given four times her proper dose of antipsychotic medication for nine days before anyone noticed the error.

As a result, the 77-year-old was sleepy, sometimes non-responsive, refused food and fluids, suffered a fall and developed a pressure sore, according to a report made public today by Deputy Health and Disability Commissioner Rose Wall.

Even after the dispensing error was corrected, the woman's condition continued to deteriorate. She was transferred to a public hospital and given palliative care. She died several weeks later.

Ms Wall found a pharmacist, a pharmacy, a rest home and a nurse manager had all breached the code of patients' rights. None was named in her report.

Although the pharmacy had five dispensary staff on duty, the pharmacist who made the dispensing error did not have anyone check her work and did not notice the incorrect dose. The pharmacy was aware the pharmacist had made a number of previous dispensing errors.

At the rest home, no medication reconciliation was done when the woman's medication arrived. On occasion the woman's records did not indicate whether medication was given and, if not, the reason why.

Ms Wall expressed a number of concerns about the rest home, including its having insufficient registered nursing hours, staff reliance on transfer documentation and poor medication management, medication reconciliation and documentation. The nurse manager failed to ensure that medications were administered safely.