A woman died in Whangārei 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 Ora Te Tai Tokerau, was also criticised for lacking policies and failing to follow existing procedures.
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.
The patient also was not told her medication had been changed to the penicillin-based antibiotic Augmentin.
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.
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.
McDowell said the woman’s death had a devastating effect on her family.
She said it was a case of human error by clinical staff, who were also clearly affected by the outcome.
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.
McDowell urged Te Whatu Ora’s national office to support the Northland health authority to implement electronic prescribing.
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.