Report hits at hospital over deadly mix-up

The daughter of an elderly woman who died after receiving another patient's morphine in Palmerston North hospital three years ago says she is grateful for a report criticising the hospital's procedures.

Health and Disability Commissioner Ron Paterson released the findings yesterday of his investigation into the care of 91-year-old Eileen Anderson in April 2002.

Mrs Anderson was given slow-release morphine and other incorrect drugs after her name sticker was mistakenly placed on another patient's drug chart.

The mix-up was not detected for four days, and Mrs Anderson died two weeks later.

Mr Paterson criticised the systems that led to the medication error.

"Palmerston North Hospital's systems allowed the care of an elderly patient to be compromised by mistakes and a lack of co-ordination," he said.

Mrs Anderson's daughter Helen McKernan said she was gratified with the outcome of the report and she thought it was fair.

"I do feel the result is going to be hugely improved procedures in place at the hospital and will enhance patient safety. And that's an excellent outcome."

Ms McKernan said she had always been concerned that it had taken so long to get such a serious incident brought to light and rectified.

"Three and a half years is a very long time for such a situation not to be completely addressed."

She said although her family was not given a formal apology, verbal apologies were made at the inquest and through the hospital's lawyers.

The process was a challenging one to go through, Ms McKernan said.

"My mother was of course the main victim, but it has had its impact on us and I feel really sorry for other families who have to go through such a lengthy complaints procedure."

In addition to being given the wrong drugs, including morphine for 4 days before the error was detected, Mrs Anderson also did not receive her regular medication for diabetes.

When the error was detected, Mrs Anderson's family was not told for three days, and Mrs Anderson died two weeks later of a chest infection and heart failure.

Mr Paterson said if the error had been detected early enough, Mrs Anderson may well have survived.

"It's a tragic comedy of errors. A black comedy really," Ms McKernan said.

Mr Paterson said the hospital had a "system set up to fail".

"There was some really practical things about the way in which charts were labelled and how they got mixed up and that set things in train," Mr Paterson told National Radio this morning.

He said compounding the problems was a shortage of staff.

"And when you've got a shortage of staff, and you've got junior staff who have not been properly oriented and trained - all of that sets things up to fail."

Mr Paterson said that did not mean individuals were not responsible as well.

But he said he was impressed that changes had been made at the hospital.

"Just some sensible practical steps that needed to be in place right at the start. Other things are going to take more time and overcoming staffing shortages, that's a real challenge."

He said mistakes like the ones made with Mrs Anderson were made at hospitals all the time, and they needed to make a "concerted effort to keep their eye on the ball".

Mid-Central Health's nursing director Sue Wood told National Radio the Commissioner's report outlining staff shortages and nursing workloads, "painted a very accurate picture".

She said the climate at the hospital between 2002 and now were poles apart.

"Our organisation is extremely committed to our patients and to our staff and we recognise that our staff, to be at their best, need to be supported by the management teams and by the systems in the organisation."

Ms Wood said there was more supervision now of junior doctors and nursing staff than there was three years ago.

"We've been building a learning culture, rather than a shame and blame that perhaps was pervading ... around those times."

She said systems had been put in place in the hospital so the errors that Mrs Anderson and her family experienced could not happen again.

- NZPA