Charting And Administration Of Prisoner’s Medications By DHB

Health and Disability Commissioner Anthony Hill today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to give a patient his regular medications while he was in hospital.

The man had been transferred to hospital from prison after he began suffering from severe flank pain. He had a medical history of high blood pressure and depression, and was taking regular medication to treat these conditions.

The man was transferred from the Emergency Department (ED) to the General Surgery ward, but his regular medications were not charted upon admission. It was not until the man was discharged from hospital three days later that it was discovered his regular medications had not been charted or administered at all during his time at hospital.

Mr Hill considered that by not charting or giving the man his regular medications, the DHB had failed to provide him with appropriate care and was therefore in breach of the Code. Mr Hill noted that the man "was put at unnecessary risk in the treatment of his depression and high blood pressure", and that the failures by the DHB were the result of "several systemic issues". These issues included a lack of clarity about which team was responsible for charting patients’ regular medications.

Mr Hill made a number of recommendations to the DHB, including that it randomly audit and report back to HDC on whether regular medications had been charted for patients admitted to General Surgery from ED, and that it develop a formal checklist and action plan. Mr Hill also recommended that the DHB apologise in writing to the man for its breach of the Code.

The full report for case 18HDC02226 can be found on HDC’s website.

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