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Identification of patient before administering medication - HDC

Fuseworks Media
Fuseworks Media

Deputy Health and Disability Commissioner Kevin Allan today released a report finding a nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for administering medication to the wrong person.

A man in prison was due for a hepatitis vaccination. His brother, who was also a prisoner at the same prison, was due for an injection of an anti-psychotic medication. Both men were scheduled to be seen at the prison’s health unit on the same day for their respective medications. The two men were similar in physical appearance and age.

When the man was brought to the holding cell outside the health unit, the nurse said she was told his brother was outside, and she believed that it was his brother that she recognised. On this basis she asked her colleague to help her cross-check the brother’s medication to confirm the correct medication was being administered to the correct patient, including checking the photograph on the medication chart. The man was not in the room when the checks were being completed.

When the man was brought out of the holding cell to the room where the medication would be administered, the nurse called out the brother’s name. She said the man answered in the affirmative and when she asked him to state his full name she believed she heard the name of his brother. She did not ask him for another form of identification, such as his date of birth.

Without telling the man the specific medication he was to receive, she injected the anti-psychotic medication intended for his brother.

Kevin Allan considered that by failing to confirm the identity of the man and provide information to him, and subsequently administering medication to the wrong person, the nurse breached the Code.

He said that had the nurse provided the man with information about the medication, this safeguard may have enabled her to realise that he was in fact there for his hepatitis vaccination, and further would have enabled the man to refuse his brother’s medication.

"Without information about the medication to be administered, the man was not in a position to make an informed choice and give his informed consent to taking the medication," Mr Allan said.

Kevin Allan recommended that the nurse apologise to the man and undergo further training. He also recommended that the Department of Corrections review its medicines management policy in light of this case.

The full report for case 18HDC01693 is available on the HDC website.

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