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Man in 90s died after receiving wrong medication in hospital

By and is republished with permission.

A man in his 90s died after being given the wrong medication in hospital, the Deputy Health and Disability Commissioner has found.

The man was originally admitted to hospital in 2018 with stroke-like symptoms, but a CT scan revealed he was having seizures.

“During his follow-up treatment he received the wrong medication, which was incorrectly prepared and administered by the two registered nurses,” Deputy Health and Disability Commissioner Vanessa Caldwell said.

“The man became unresponsive, was moved to the ICU and passed away three days later from pneumonia following an overdose of the incorrect medication.”

The two nurses involved in the man’s care were found to have breached the district health board’s policy and the New Zealand Nurses Organisation’s guidelines, with the DHB criticised for its “unclear policy and its storage of the medication”.

The findings explain that the nurses went to the medical room on the ward to retrieve diazepam and levetiracetam for the patient. Levetiracetam is used to treat seizures.

When one of the nurses asked the pharmacy technician where the levetiracetam was, she replied “it’s on the shelf”.

The nurse found the diazepam but could not find the levetiracetam, so she asked the second nurse if they had run out.

The second nurse “informed her that the levetiracetam had been moved to the shelf opposite, with the other injectable drugs”.

The first nurse then “went to retrieve the levetiracetam from the shelf and saw a medication beginning with ‘lev’ and selected it believing that it was levetiracetam” when it was actually levomepromazine, an anti-psychotic medication.

The second nurse checked the box and also mistook the name.

In her statement to police, the pharmacy technician said she questioned the dose, as 500mg of levomepromazine “felt wrong”, but the first nurse “confirmed to her that it was the correct dose”.

A doctor said that “if he was going to prescribe [levomepromazine], the quantity of the script would have been something like 6 [mg]”.

The error was discovered after the pharmacy technician later mentioned the dose to a colleague, who said the amount wasn’t “okay”.

When two other pharmacists “arrived in the drug room they found 20 open ampoules of levomepromazine and began to panic”.

One of them found the second nurse and asked if they’d administrated those vials to the man, and the pharmacist “cannot remember [the nurse’s] response, but could tell by the look on her face that the patient had received the wrong medication”.

Clinical records state that 210mg of the medication had been given by the time the infusion was turned off.

Both nurses have apologised to the man’s family.