Systems failures result in an elderly woman being repeatedly administered incorrect doses of warfarin

The importance of aged residential care facilities having appropriate systems in place to ensure nursing staff administer critically important medications correctly, and for medication errors to be identified and followed up in a timely manner, was highlighted in a decision published by Deputy Commissioner, Rose Wall.

In her decision, Ms Wall found Sunrise Healthcare Limited (trading as West Harbour Gardens) in breach of the Code of Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill.

An elderly woman was admitted to West Harbour Gardens (WHG) due to a cognitive impairment and a significant deterioration in her health which required hospital-level care. The woman had multiple medical conditions including a heart condition (atrial fibrillation), for which she was prescribed warfarin.

Warfarin is an anticoagulant medication prescribed to maintain a person’s blood-clotting function within a therapeutic range. Blood tests are regularly undertaken to monitor patients who are prescribed warfarin, with the dose of warfarin adjusted in response to the results. The woman was administered the incorrect dose of warfarin on six occasions by six nurses at WHG. On another occasion the administration and documentation for the woman’s warfarin medication was incomplete.

Ms Wall noted that "Sunrise Healthcare’s duty to provide services to the woman with reasonable care and skill included responsibility for the actions of its staff at WHG. It also has a duty to comply with the New Zealand Health and Disability Services (Core) Standards."

"Systems failures at WHG meant the woman was administered incorrect doses of warfarin on a number of occasions by a number of different clinical staff, and the errors were not identified until almost a year later following a complaint from the family.

"I cannot over-emphasise the potentially serious consequence of the woman not receiving her prescribed dosage of warfarin," said Ms Wall.

Ms Wall was also critical that WHG’s Medication Management Policy and Procedures did not include recommended practice regarding quality and risk management of medication errors and open disclosure to the consumer, and in this instance her family.

"When the errors were identified, they were not documented in an incident report form, no investigation report was completed, and corrective actions were not documented formally. As such, the opportunity to identify the cause of the medication errors and implement remedial actions in a timely manner was lost," said Ms Wall.

Ms Wall recommended Sunrise Healthcare audit any medication errors at WHG (over a three-month period); review the Critical Incident Reporting policy and include a restorative approach to investigating incidents; review and update the Medication Management Policy and Procedures, and provide a formal written apology to the woman and her family.

WHG has made a number of changes following the events of this case. They have started using the electronic medication management system, Medi-Map instead of paper-based signing sheets, they have reviewed their policies, and issued a new Community Practitioner Policy for prescriptions and supply of medications, and they have required their nurses to update their medication competencies. In addition regular checks are undertaken to ensure the dispensing of medication is documented correctly.

"I am pleased to see WHG has completed extensive reviews of their policies, and made the changes to its processes which will lead to improved service delivery for residents in their care," says Ms Wall.