A medication error by a nurse at Middlemore Hospital led to a woman overdosing on fentanyl.
A report released today by Deputy Health and Disability Commissioner Dr Vanessa Caldwell outlined what happened during the woman's visit to Middlemore Hospital in 2019 for a routine haemodialysis (dialysis) treatment.
"A registered nurse (who was the woman’s primary nurse for that visit), made a medication error that led to an overdose of fentanyl (a controlled drug)," the report states of what happened to the women aged in her 50s.
"The medication (naloxone) given to counteract the fentanyl caused the woman significant pain and distress."
The error came about after the registered nurse (RN) grabbed the fentanyl from a dispensing machine without having it prepared and checked by a second nurse.
"This is contrary to the requirement of Te Whatu Ora Counties Manukau’s policy. Later the RN picked up the fentanyl medication, mistaking it for another medication, and administered an incorrect dose to the woman. The RN immediately realised the error and reported it."
Dr Caldwell found the RN breached the Code of Health and Disability Services Consumers' Rights in multiple ways.
"Fentanyl is a strong opioid that requires careful preparation and administration owing to its potency," said Dr Caldwell. "The RN had a duty of care to the patient to prepare the fentanyl safely, in accordance with CMDHB’s Intravenous Opioid Protocol."
Dr Caldwell also found Te Whatu Ora breached a portion of the Code due to the, "practice of nursing staff on the dialysis unit to inappropriately remove medication from the dispensing machine before it was required".
The report made a number of recommendations for Te Whatu Ora Counties Manukau, including it provide a written apology to the patient involved.
Since the complaint, Te Whatu Ora has reportedly made a number of changes to ensure a repeat of the incident doesn't occur again.
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