Record-keeping error led to patient overdose in Highland hospital
Health chiefs have been ordered to apologise to a dialysis patient after a medication overdose.
NHS Highland was ordered to apologise to the patient and their spouse for "poor record keeping" and for the extra dose of medication that was administered as a result.
The Scottish Public Services Ombudsman (SPSO) issued the order after carrying out an investigation into the incident, which occurred in an unspecified hospital in the region.
The patient's spouse – referred to in the SPSO report only as 'C' – complained to the ombudsman after realising that their partner (referred to as 'A') had been given an accidental overdose.
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The incident occurred when patient A was admitted to hospital with pain, spasms and weakness in their right leg, which was later diagnosed as being caused by an infection in the muscles between the lower spine and thigh.
A is a dialysis patient and had also previously suffered a stroke, leaving them with weakness on the right side and wheelchair bound.
The SPSO report stated that "C therefore usually supports A with dialysis and medication" as a result of her ongoing conditions.
And it added that the complaint arose in the first week of A's hospital admission when both C and a nurse separately administered A's evening medication.
C stated that they had previously been given the medication by ward staff to support A and C had administered the evening medication before going out for a few hours.
On their return they had found A "to be unresponsive".
It then emerged that a nurse had also administered evening medication, at which point C complained that an overdose of medication had occurred and that record keeping and incident management had been "unreasonable".
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Making its findings, SPSO said: "We took independent advice from a nursing adviser. We considered that this incident should not have happened, and that it indicated a lack of clarity, process, recording and communication within the ward.
"We found that record keeping before and after the incident had been lacking, as there had been no clear record in a person-centred care plan to state that the medication was being held and administered by C, that there had been a 24-hour gap in nursing records over the period of the incident and that no extra observations or conversations with a doctor had been recorded following the incident.
"We found that categorisation and management of the incident had been unreasonable. We upheld the complaint."
SPSO issued two recommedations – that NHS Highland apologise to the couple for the health board's "poor record keeping" in this instance, and also apologise that an extra dose of medication was administered.
It added: "We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set."
