A woman's heart rate dropped to just 22 beats per minute after an anaesthetist gave morphine to her without consent.
A report released on Monday by Deputy Health and Disability Commissioner Deborah James outlines how the anaesthetist administered the drug during surgery, despite having evidence of the patient's adverse reaction to morphine in the past.
"A woman underwent a hysterectomy in 2019. Prior to the surgery, the woman made her concerns regarding morphine administration known to Te Whatu Ora (previously DHB) staff and the anaesthetist, including her understanding that morphine could cause her heart rate to slow to an abnormally low rate," the report reads.
However, during the surgery the anaesthetist gave the woman 3mg of morphine.
"He thought this would give her better pain control after the surgery, and that giving a small dose in theatre under anaesthetic with continuous monitoring would allow him to establish if it was a safe drug for the woman. However, the anaesthetist had not obtained the woman’s informed consent for this prior to surgery. To her surprise, the woman was informed post-surgery that morphine had been administered to her."
After being administered the drug the woman's heart rate dropped to just 22bpm.
James found the woman had a medic alert bracelet stating morphine would cause severe bradycardia. The bracelet was removed from her wrist along with other jewellery prior to the operation and replaced with a red alert band.
The anaesthetist said he was unaware of the bracelet and didn't recall seeing it on the patient's notes.
James' report recommended the anaesthetist undertake further education and training on informed consent, and report back to HDC on completion of the training. She also recommended any medic alert bracelets be properly checked in and documented prior to any surgical procedure.
The anaesthetist has since implemented these changes to his practice according to the HDC.
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