Elderly woman given the wrong dose of medicine six times, by six different nurses

Six West Harbor Gardens nurses administered the wrong dosage of blood-thinning medication to a patient.  (File photo)


Six West Harbor Gardens nurses administered the wrong dosage of blood-thinning medication to a patient. (File photo)

An elderly woman living in an aged care facility was given the wrong dose of blood thinners six times, by six different nurses, over a period of five months.

On Monday, the deputy Health and Disability Commissioner Rose Wall has found that Sunrise Healthcare Limited (trading as West Harbor Gardens) breached the Code of Health and Disability Consumer Rights for failings in its care of a woman, named Ms A.

In 2015, Ms A, 90, was admitted to West Harbor Gardens residential care center in West Auckland. She needed hospital treatment.

Mrs. A had a heart condition for which she was prescribed warfarin (anti coagulants).

* A teenager took antidepressants instead of migraine medication for six months after a pharmacy mistake
* Woman started IVF while already pregnant, clinic asked to apologize
* Timaru nursing home gave ‘inadequate care’ to dementia patient

Over a five-month period between July and November 2018, six West Harbor Gardens nurses gave Ms A the wrong dose of warfarin.


Health Minister Andrew Little speaks with Stuff reporter Rachel Thomas about the pressures on the healthcare system, nurses’ pay and how he plans to address labor shortages.

There were six occasions when 3 mg of warfarin was administered instead of the 2 mg indicated.

On another occasion, the administration and documentation of the drug was left incomplete.

The medication errors were not identified until a year after they occurred, when West Harbor Gardens responded to complaints made by Ms A’s family about her general care while at the facility.

There was no evidence that the care facility ever undertook a formal investigation into the matter and told HDC it could not locate the incident report.

Ms A’s daughter said the family was not informed of the errors.

Wall said “systemic failures” at West Harbor Gardens led to Ms A being given the wrong dose of medication on multiple occasions.

“I cannot stress enough the potentially serious consequence for the woman not to receive the dose of warfarin that has been prescribed for her.”

She criticized the facility’s policies and procedures that did not include open disclosure with Ms A’s family.

“When errors were identified, they were not documented in an incident report form, no investigation report was written, and corrective actions were not formally documented.

“Thus, the opportunity to identify the cause of medication errors and implement corrective measures in a timely manner was lost,” she said.

Wall recommended that Sunrise Healthcare provide Ms. A and her family with a formal written apology.

She also recommended that Sunrise Healthcare verify all medication errors at West Harbor Gardens over a three-month period and review its critical incident reporting policy.

Since the incidents involving Ms. A were identified, West Harbor Gardens has made a number of changes to ensure the medications were administered correctly, Wall said.

The establishment has been contacted for comments.

Comments are closed.