A district health board who sent an elderly woman home with the wrong medication has been found to have breached the Code of Health and Disability Services Consumers' Rights.

Health and Disability Commissioner Anthony Hill today released a report with the finding, which was made after the woman became unwell from taking the incorrect medication she had been accidentally given, requiring her to return to hospital.

The woman was originally admitted to a public hospital for treatment, bringing her personal medications with her.

During the woman's admission, her medications were kept in the public hospital's medication room in an unlabelled bag placed in a container labelled with the woman's name and room number.


Following treatment, a registered nurse was responsible for the woman's discharge.

The woman's son asked the nurse for the woman's personal medications to be returned to her.

The nurse went to the medication room, taking the unlabelled bag from the container labelled with the woman's name and room number.

She did not check that the bag contained the woman's medications, and as it transpired the bag also contained another patient's medications, which the woman took home, unaware that some of the medications were not her own.

The woman took both sets of medications and became unwell, requiring a further hospital admission.

Mr Hill found that by having inadequate systems in place for the storage and return of medications brought in to hospital by patients, the DHB did not provide services to the woman with reasonable care and skill.

Mr Hill made adverse comment about the nurse's failure to check the medications she was returning to the woman.

Mr Hill recommended that the DHB and the nurse apologise to the woman. He also recommended that the DHB review and amend its medicines management policy to optimise safety and accuracy when returning medications to patients, and provide training to staff on this policy and on safe medication management.