A nurse at a New Plymouth rest home has been asked to apologise to an elderly man’s family after she mistakenly gave him five times the maximum prescribed dose of morphine leading to his death.
Deputy Health and Disability Commissioner Rose Wall today released a report on the incident which took place at Molly Ryan Lifecare and Retirement Village.
It begins by stating the man, who was in his eighties, had multiple existing health conditions and was prescribed morphine for worsening pain.
“One morning, a registered nurse and two caregivers were on duty,” the report states.
It adds that none of these staff members had met the medication competency requirements set out in the rest home’s Medication Management policy.
“Medication competency was a requirement before staff were allowed to administer stock-controlled medications such as morphine.
“During the shift, the nurse was told that the man appeared to be distressed. She drew up 2.5ml of subcutaneous morphine solution without checking the prescribed route of administration or calculating the dose.
“The solution administered to the man contained 25mg of morphine, which exceeded the maximum quantity prescribed by a factor of five. The nurse administered the solution orally early in the morning. In the early afternoon, it was reported that the man was unresponsive, and he sadly died that evening,” the report reads.
Due to this Deputy Commissioner Rose Wall found the rest home provider failed to provide the man with a service from suitably qualified/skilled and/or experienced service providers.
She also said Molly Ryan failed to ensure that the systems in place were sufficiently robust to ensure that all staff complied with its Medication Management Policy.
"I am concerned that at the time of these events, the systems in place at Molly Ryan were not sufficiently robust to ensure that all staff complied with the Medication Management Policy," Wall said.
"Medication-competency training had not been fully completed by staff with responsibility for medication management before they were rostered on duty and, as such, the staff concerned were not supported to administer medication safely, and were not suitably skilled to deliver the standard of care required."
Wall found the administering nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for administering medication without checking the appropriate route or calculating the appropriate dosage.
She made a number of recommendations to the retirement village to ensure a repeat of the incident doesn’t happen again and recommended two of the nurses involved provide a written apology to the family of the man.
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