Key Takeaways
- An elderly woman was given ten times the prescribed saline solution in the hours before her death in Oamaru Hospital.
- The Health and Disability Commissioner has told Waitaki District Health Services to apologize to the family of the 93-year-old woman.
- The doctor responsible for the mistake has accepted that he was unfamiliar with prescribing hypertonic solution and did not follow proper guidelines.
- The commissioner has recommended that Health New Zealand Te Whatu Ora Southern provide training for staff in emergency departments and rural hospitals on the management of hyponatraemia.
- The incident highlights the importance of proper medication administration and monitoring in hospitals, particularly in emergency departments and rural hospitals.
Introduction to the Incident
The incident in question involved a 93-year-old woman who was referred to the Oamaru Hospital’s emergency department in November 2023 due to an abnormally low concentration of sodium in the blood, along with a "chesty cough". The woman was prescribed a bolus of 100ml of 3% saline at a rate of 200ml per hour with a further check scheduled at 9pm by the duty doctor. However, due to a mistake, the woman was given ten times the prescribed amount of saline solution, which led to a rapid increase in her sodium levels and ultimately resulted in her death.
The Events Leading Up to the Woman’s Death
The events leading up to the woman’s death were outlined in the commissioner’s 28-page decision. The duty doctor, Dr B, prescribed the initial dose of saline solution, but before the scheduled check, the woman’s care was handed over to Dr C. The nurses informed Dr C that the saline course had finished, but unbeknownst to him, a registered nurse had picked up a 1000ml bag of saline solution instead of a 100ml bag. Dr C then prescribed another 1000ml bag of 3% saline to run over 10 hours, without realizing the mistake. The woman’s blood pressure and urine output were measured as high, but there was no change to the treatment plan.
The Mistake and its Consequences
The mistake was not discovered until the morning handover, when Dr B noticed the woman’s sodium levels had risen rapidly. He ordered her fluids stopped and began a sodium-reduction process, but eventually noted the woman was too frail for such aggressive treatment. The woman was provided with comfort care and died shortly afterwards. The commissioner’s independent adviser stated that the workload at the time of the woman’s admission was "at the limit of what can be considered safe", which may have contributed to the mistake.
The Commissioner’s Decision
The Health and Disability Commissioner has told Waitaki District Health Services to apologize to the family of the 93-year-old woman. The commissioner’s decision laid out the timeline of events and highlighted the mistakes made by the doctors and nurses involved. The commissioner noted that Dr C accepted he was unfamiliar with prescribing hypertonic solution and did not take the time to assess his prescribing decision comprehensively. The commissioner also recommended that Health New Zealand Te Whatu Ora Southern provide training for staff in emergency departments and rural hospitals on the management of hyponatraemia, with reference to this case.
Conclusion and Recommendations
The incident highlights the importance of proper medication administration and monitoring in hospitals, particularly in emergency departments and rural hospitals. The commissioner’s decision and recommendations emphasize the need for healthcare professionals to prioritize patient care and be aware of red flags in patients who need further consideration. The apology from Waitaki District Health Services and the recommended training for staff are steps towards preventing similar incidents in the future. The case serves as a reminder of the importance of vigilance and attention to detail in healthcare, and the need for healthcare professionals to stay up-to-date with the latest guidelines and best practices.