Nurse gave heart patient wrong drug
Mon, 15 Oct 2012 3:55p.m.
A senior nurse who gave the wrong drugs to a heart patient who died hours later may face professional misconduct charges.
A 69-year-old man died less than two hours after the unnamed nurse gave him another patient's medication.
The nurse, who has since stopped practising, overrode a hospital medication administration system to give him three drugs, one of which was a beta-blocker, solatol.
The unnamed patient, who had a slow heart rate, should not have been given the beta-blocker.
The Health and Disciplinary Commissioner has referred the nurse to its director of proceedings who has yet to decide if any further action will be taken.
The man, admitted to the unnamed hospital on a Saturday late in 2010, was diagnosed as suffering from a heart attack as well as other serious health issues including blood cancer.
He was moved to a medical ward and on the Monday the nurse failed to notice the man's condition had deteriorated and did not ask for help.
He was given the wrong drugs later that day while another medication he was supposed to get was withheld and he died at 7:10pm.
The nurse realised her error with the medication before the patient died but did not call for a doctor and only reported her mistake two days after the incident.
The Health and Disability Commissioner Anthony Hill said the nurse breached the patient's rights for administering incorrect medication, failing to discuss with a prescriber that she had withheld medication, failing to immediately report the medication error and seek a medical review, and failing to recognise the significance of the man's deteriorating condition.
The DHB that the nurse worked for was not found to be in breach of its obligations as the breaches were caused by individual error.
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16/10/2012 1:39:46 a.m.
Retired Respiratory Care Practitioner wrote:
I worked for 13 years as a Respiratory Care Practitioner in the hospital Emergency Room and Intensive Care environment. I have seen my share of mistakes made either through poor judgment, incompetent health care workers that simply didn’t pay attention to what they are doing, others that lacked the training or knowledge to perform a task or even knowingly make a mistake but refuse to admit that they have done so because of the little known super-inflated “God” complex that exists among some within the health care environment. However, when someone makes a mistake and a death occurs, the situation becomes far more serious. Concerning this case reported by TV3, if in fact the Nurse involved in this case knew she made a mistake, willfully withheld her mistake from the patient’s Doctor and even waited 2 days after the patient’s death to admit her mistake then this Nurse has crossed “over the line”. There is a difference between a human error that could have possibly been reversed by medical intervention if she immediately notified the medical staff/patient’s Doctor and criminal negligence resulting in the death of a patient. Apologies from this Nurse are unacceptable. They will not bring back the life of the patient. She was directly responsible for this patient’s death…100% and she must be held accountable. All to many times here in NZ, someone’s life is destroyed and those responsible think that an apology is good enough. Regardless of how sad this is, this Nurse's license to practice must be revoked indefinitely and she should face serious criminal charges for her negligent actions that caused the death of a patient under her care. Ask yourselves, how would YOU feel if your loved one died as the direct result of a Nurse that simply made a mistake or a Nurse that made a mistake and didn't bother to come forward until your loved one was dead only to say, "Oops....Sorry about that".
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