A series of mistakes lead to patient's death: a Health and Disability Commissioner case highlights the importance of registered nurses reading all documentation accompanying a patient and of the need for dear communication.
Subject: Communication in medicine (Methods)
Medical errors (Prevention)
Practice guidelines (Medicine) (Evaluation)
Registered nurses (Practice)
Registered nurses (Ethical aspects)
Registered nurses (Behavior)
Patients (Care and treatment)
Patients (Management)
Authors: Rose, Karen
Gilmour, Cathy
Pub Date: 02/01/2009
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: Feb, 2009 Source Volume: 15 Source Issue: 1
Topic: Event Code: 200 Management dynamics; 290 Public affairs Advertising Code: 91 Ethics Computer Subject: Company business management
Product: Product Code: 8043110 Nurses, Registered NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners SIC Code: 8049 Offices of health practitioners, not elsewhere classified
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 194904197
Full Text: Registered nurses' poor documentation and communication and their failure to follow up medication queries resulted in the death of a patient, in a case investigated by the Health and Disability Commissioner. (1) The patient, who had been transferred from a public hospital to a rest-home, collapsed and had to be readmitted to hospital The patient died two weeks later.

The Commissioner, in a decision released in October last year, was concerned none of the RNs appeared to have read or understood the discharge documentation that accompanied the patient from the hospital. (1) Also, there was no apparent nursing plan for the patient--had there been a plan, some of the matters that were overlooked, may not have been.

This is an alert to all RNs of the need to ensure they are aware of and read all the documentation that comes with the patient and that if they don't understand anything, they ask whoever they need to, until they get the required response. It is not okay to do nothing!

The patient--an elderly woman--was transferred from the hospital to an aged-care facility, following treatment for pneumonia, urinary retention and a rapid and irregular heart rate. She had a medical history that included cerebrovascular disease, post-cerebral vascular accident epilepsy, ischaemic heart disease, atrial fibrillation, severe aortic stenosis and significant cognitive impairment. She had developed a clot in her right arm while in hospital and this had been removed prior to her transfer. Her hospital discharge forms summarised her condition and treatment at the hospital and listed her current medications. The forms showed she had been prescribed Warfarin, Metamucil and Augmentin and indicated the amounts to be given.

However, over the next three to four days the woman did not receive the medication because the RN on duty was unsure of the dosage required and therefore failed to give the medication. This was despite concerns being raised by the woman's daughter about the medication on several occasions. The RN had raised the medication issue with the nurse manager bur due to a misunderstanding between the two of them, as to whether the medication had actually been charted or was a verbal instruction only, the medication was still not given. Three days later the woman collapsed and was urgently readmitted to hospital where she died two weeks later. The medical certificate gives the cause of death as pneumonia following a stroke.

The Health and Disability Commissioner stated that: "There is a fundamental requirement that a rest-home will administer prescribed medications in a safe and consistent manner to an elderly patient who has been discharged from hospital. A series o f errors, starting at the admission procedure at the rest-home, caused the multiple drug errors which led to the woman not receiving the correctly charted drugs." (1)

The aged-care facility was found to be in breach of Right 4(1) of the Code of Health and Disability Services Consumers' Rights (the Code) by failing to ensure the patient received services provided with reasonable care.

The RN who failed to give the Warfarin over the four days was found to be in breach of Rights 4(1) and Right 4(2) of the Code for not providing services with reasonable care and skill, failing to meet the standard expected of an RN, and failing to comply with the aged-care facility's own policy for documenting medications.

Six fundamental mistakes

There were six fundamental mistakes relating to this case. They were:

1) Only the first page of the prescription form was faxed to the pharmacy and GP, therefore two of the prescribed drugs (Augmentin and Metamucil) were not scripted by the pharmacy and therefore not administered.

2) The hospital doctor's instructions were not correctly interpreted and transcribed to the resident's medication profile at admission. The patient's daughter raised the issue of the "missing" medications (Warfarin, Augmentin and Metamucil) on at least three occasions. No conversations with the daughter regarding the missing medications were documented. She then raised it with the nurse manager who, after initially saying that as the medications came in blister packs they would be correct, checked and found that only one page of medications was on the patient's file.

3) The RNs did not read all the discharge documents thoroughly or with understanding. No attempts were made to clarify the medication orders. Having recognised that they didn't understand the instructions, it was not good enough to simply wait.

4) The RN decided to withhold the Warfarin over the weekend without documenting that decision or seeking medical advice or clarification. The RNs failed to take responsibility for the administration of the medication on their shifts. The failure to seek support or to question when unsure showed poor nursing judgement.

5) An RN discussed the Warfarin matter with the nurse manager who advised that, as the doctor was visiting tater that day, the RN could check with him. This conversation was not recorded.

6) The visiting doctor's order regarding the Warfarin, after being questioned by one of the RNs, was discussed with the nurse manager. The RN failed to interpret the nurse manager's instruction re the "verbal order" and again withheld the medication. This was not followed up by the RN or the nurse manager. The doctor had written in the medical notes but not on the drug sheet, which is where the RN had looked.


This case amply demonstrates the need for RNs to document properly, to communicate clearly with one another and with patients' family members, and to follow up any situation in which there is any doubt as to what should be done.


(1) 07HDC11952. (2008) Rest home/Registered nurse. Warfarin administration in a rest home. http://www.hdc.org.nz/complaints/ opinions?recent. Retrieved 28/01/09.

By legal adviser Karen Rose and professional nursing adviser Cathy Gilmour
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