An unnamed anaesthetist gave a patient more than twice the intended amount of morphine during a back operation.
Photo: 123rf
In a report today, the Health and Disability Commissioner Anthony Hill said the anaesthetist breached patient rights in the incident last year.
Pain relief was being given to a patient epidurally during spinal surgery in a private hospital operating theatre.
The patient was under a general anaesthetic. The error occurred when the anaesthetist administered an extra 6 milligrams of morphine epidurally, on top of the prescribed 2 point 5 milligrams of the drug.
Instead of the extra morphine, he had intended to give a 10 milligram mixture of the painkiller Fentanyl and a local anaesthetic, Ropivacaine.
The anaesthetist, Dr D, said his "slip/lapse" mistake occurred because he picked up a syringe intended for another patient.
He said the syringe was "in close proximity" to the correct syringe on the drug trolley.
Dr D said all the syringes were labelled correctly, and he discovered the error when the next patient's epidural had two ropivacaine/fentanyl syringes and no morphine syringe.
A record-keeping system used to track the drugs used during operations could have alerted the doctor to the error but did not.
Health and Disability Commissioner Anthony Hill. Photo: Supplied
Mr Hill said this was because Dr D did not know how to link a scanned drug to an epidural. He said Dr D was also worried about carrying out the record-keeping process during an epidural, which required sterility.
A speaker in the operating room, that could have alerted doctors to the error if the record-keeping system had been used, was not turned on.
Mr Hill said the patient was kept in the intensive care unit for observation overnight, and discharged later.
He said Dr D did realise his mistake, and had apologised to the patient, who was unharmed.
The anaesthetist had notified the patient and her family quickly, reviewed his practice in relation to injectable drug safety, and had undertaken extra self-learning on the record-keeping system, Mr Hill said.
Flaw in record-keeping system identified
However, Mr Hill said the anaesthetist ought to have ensured he was giving the correct drugs and had not undertaken an alternative check before giving the drugs.
"This is suboptimal. In my view, the safe administration of drugs in anaesthesia cannot be compromised, as failing to do so, particularly in relation to the epidural space, can have potentially life-threatening consequences for the patient."
Mr Hill did not criticise the doctor over his lack of use of the record-keeping system.
"However in my view there is a flaw in the record-keeping system if there is no way to enter data into the system during a sterile procedure. This flaw needs to be addressed."
The drug-administration error was a result of an individual clinical error and individual decision-making and not a failure by the private hospital, he said.
