A woman died in Whang\u0101rei Hospital after she was given penicillin despite a severe allergy, a new report by the Health and Disability Commissioner has revealed.<\/p>\n
The commissioner found two doctors and a nurse breached the patient’s rights to have services provided with reasonable care and skill.<\/p>\n
The Northland District Health Board, now Te Whatu Ora Te Tai Tokerau, was also criticised for lacking policies and failing to follow existing procedures.<\/p>\n
The woman, in her 80s, was admitted to hospital in 2020 following complications from earlier elective surgery. She had a well-documented severe penicillin allergy, but that was not checked when she was moved to a different ward and her medication was changed.<\/p>\n
The patient also was not told her medication had been changed to the penicillin-based antibiotic Augmentin.<\/p>\n
Health and Disability Commissioner Morag McDowell called on Te Whatu Ora’s national office to work with Northland health authorities to bring in electronic prescribing in a bid to prevent future medication errors.<\/p>\n
Inflexible rostering, resulting in inadequate staffing levels during a busy weekend when the hospital had many acutely ill patients, and an inconsistent handover process, played a part in the fatal error.<\/p>\n
McDowell said the woman’s death had a devastating effect on her family.<\/p>\n
She said it was a case of human error by clinical staff, who were also clearly affected by the outcome.<\/p>\n
Te Whatu Ora Te Tai Tokerau accepted systemic factors within the organisation contributed to the error, and agreed electronic prescribing was key to preventing future medication errors – but pointed out it had been asking for electronic prescribing to be prioritised for many years.<\/p>\n
McDowell urged Te Whatu Ora’s national office to support the Northland health authority to implement electronic prescribing.<\/p>\n
She also recommended Te Whatu Ora Te Tai Tokerau consider how to improve recognition of known drug allergies; improve handover processes to make sure important information was passed between teams; amend its policy to make it clear prescribers had to inform patients about changes to their medication and ask about allergies; and provide evidence that staff were using electronic clinical information at the bedside.<\/p>\n
Source: RNZ<\/p>\n","protected":false},"excerpt":{"rendered":"
A woman died in Whang\u0101rei Hospital after she was given penicillin despite a severe allergy, a new report by the Health and Disability Commissioner has revealed. The commissioner found two doctors and a nurse breached the patient’s rights to have services provided with reasonable care and skill. The Northland District Health Board, now Te Whatu […]<\/p>\n","protected":false},"author":6,"featured_media":7785,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[174],"tags":[],"class_list":["post-7784","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nz-news"],"amp_enabled":true,"_links":{"self":[{"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/posts\/7784","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=7784"}],"version-history":[{"count":1,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/posts\/7784\/revisions"}],"predecessor-version":[{"id":7786,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/posts\/7784\/revisions\/7786"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=\/wp\/v2\/media\/7785"}],"wp:attachment":[{"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=7784"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=7784"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/thebuzz.apnanetwork.co.nz\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=7784"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}