KEY POINTS:
A third case of a fatal drug mix-up has emerged, with a finding by the Health and Disability Commission about the death of an elderly woman.
Coroners ruled this week that medication errors contributed to the death of a 62-year-old Canadian man in Wanganui Hospital in 2006, and to the death of a 76-year-old man in Hawke's Bay Hospital in January.
The commission inquired into the death of an 89-year-old woman at an undisclosed location.
She was discharged from hospital on June 22 last year, after being treated for pneumonia, an irregular heartbeat and other problems.
While in hospital, she had also developed a blood clot in her arm and was prescribed warfarin, a blood-thinning medication, to prevent strokes, the Dominion Post reported.
The specialist who discharged her from hospital on a Friday wrote detailed instructions for her medication regime and told the rest home she would need more blood tests on the following Monday.
The first mistake happened when the new manager - who had been in the job less than a month - failed to fax both pages of the prescription to the pharmacy and GP, so some drugs were missed.
The duty nurse then misinterpreted the GP's instructions and gave the patient just one milligram of warfarin instead of three or four milligrams.
The mistake was compounded the next day when another duty nurse, Ms D, noted the hospital doctor's original directions but found them confusing and decided to stop the blood-thinning medication until she could check it with the doctor.
The patient's daughter raised concerns about her mother's medication with staff several times during the weekend but it was not until the Tuesday - five days after the woman was admitted - that the correct dose was finally given.
On the Wednesday, she suffered a stroke and died in hospital several weeks later.
The hospital specialist complained to the commission in July 2007, supported by the woman's daughter.
Expert nursing adviser Jan Featherston said a "series of errors starting at the admission procedure caused the multiple drug errors".
Deputy Health and Disability Commissioner Rae Lamb said various failings by individuals had contributed to the woman's death, but the rest home and rest home company must share responsibility, as systems had obviously been under pressure.
The nurse who stopped the warfarin during the weekend was also judged to have breached the code of patient rights.
As an experienced nurse, the new manager should have been on the alert for "red flag" problems with the patient.
The Nursing Council has been asked to consider carrying out a competency review on the nurse who allowed several errors to happen during the admission procedure.
The rest home and staff have apologised to the patient's family and implemented several systems changes and staff training.
- NZPA
