Incorrect administration of medication 16HDC01162

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide a resident with an appropriate standard of care.

The resident, a woman in her seventies, received incorrect medication on two separate occasions. On the first she was given another resident’s medication, and on the second she was given an incorrect dosage of her prescribed medicine warfarin over a two day period. On both occasions the caregivers who administered the medicine did not follow the rest home’s Medication Management Guidelines.

Ms Wall said the rest home needed to have adequate systems, policies and procedures in place to support the safe and appropriate administration of medication, and to ensure that they are complied with and that staff respond appropriately when errors are made.

"There were a number of failings with regard to the management of medication and the subsequent care provided," said Ms Wall. She said the rest home failed to ensure staff followed good medication administration practices or their internal guidelines and that it failed to provide adequate oversight to ensure that staff followed relevant professional standards. She also found it did not have adequate systems and processes in place to prevent medication errors from occurring or re-occurring.

"All medication should be administered correctly. However, it is particularly significant in circumstances where rest homes are using caregivers to give medications such as warfarin where both the correct timing and correct dosage are highly important to the wellbeing of the person receiving that medication," Ms Wall said.

Ms Wall recommended that the rest home provide the woman’s family with a written apology. She also recommended the rest home provide HDC with an update on the changes put in place following the medication errors and on the home’s training and requirements for ongoing medication competency. Further to this, she recommended the rest home obtain an independent audit of the frequency and nature of medication errors over the previous six months, and provide a report on the impact of any medication errors and the steps taken to prevent further errors from occurring.

The case report is available on the HDC website.

ENDS

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