The Health and Disability Commissioner has found "human error" led to an elderly woman dying in 2020 after she was prescribed antibiotics even though she had a severe penicillin allergy.
The woman, who was in her eighties at the time, was admitted to Whangārei Hospital with a fever and abdominal pain after having elective surgery.
She had a long-standing allergy to penicillin and was known to go into anaphylactic shock in response to it.
During her five-day admission to hospital, she was transferred between a surgical ward and a general medicine ward.
Following the transfer, the senior medical officer directed the house officer to change her antibiotic to Augmentin (a penicillin-based antibiotic).
The doctors didn't inform the woman of the antibiotic change and there was "inadequate" checking of whether she had any adverse reactions or allergies before prescribing or administering the antibiotic.
She was subsequently prescribed and administered Augmentin then suffered a severe anaphylactic reaction and died.
In a report released on Monday, Health and Disability Commissioner Morag McDowell found the Northland District Health Board (DHB) (now Te Whatu Ora Te Tai Tokerau), a senior medical officer, house officer and registered nurse breached the Code of Health and Disability Services Consumer’s Rights (the Code) in the prescribing and administering of antibiotics to the woman.
"The Commissioner considered that when the senior medical officer directed the house officer to prescribe the Augmentin without first checking for adverse reactions or allergies, and when the house officer prescribed the Augmentin for the woman without first checking for adverse reactions or allergies, the woman was not provided services with reasonable care and skill," the report said.
It was also found Te Whatu Ora Te Tai Tokerau breached Right 4(1) of the Code for a lack of policies and failing to adhere to existing procedures.
McDowell was critical of a "lack of flexibility" to enable adequate staffing during a busy weekend with several high-acuity patients and of the handover process which did not consistently support the sharing of important information such as medication allergies.
She said the error had a "devastating" impact on the woman's family but noted the mistake was "human error" by clinical staff who were also "clearly affected by the outcome".
"Te Whatu Ora Te Tai Tokerau accepted that systemic factors contributed to the error and agreed electronic prescribing is key to preventing medication errors and that it had been requesting for this to be prioritised for many years," McDowell said.
She recommended Te Whatu Ora National office liaise with Te Whatu Ora Te Tai Tokerau (Northland District) about how it can support Te Tai Tokerau in implementing electronic prescribing.
McDowell also recommended Te Whatu Ora Te Tai Tokerau consider how it can improve recognition of documented drug allergies and implement improvements that mitigate the risk of inadvertent administration of a drug to which the patient is allergic.
She also recommended Te Whatu Ora Te Tai Tokerau improve the process and documentation of handing over information important for safe care between staff and teams, amend policy to make it clear that prescribers must inform consumers of changes to their medication and ask about allergies and provide evidence staff use electronic clinical information at the bedside.
