An elderly man suffering seizures was given the wrong medication by nurses and died a few days later because of the resulting overdose.

The man, in his 90s, was given more than three times the recommended dose of levomepromazine after two nurses mistook it for his prescribed drug levetiracetam. As a consequence, he died three days later.

Following the man’s death, one of the nurses resigned, expressing her difficulty in acknowledging the mistakes she and her colleague made that “caused the death” of the patient identified as Mr A in a Health and Disability Commissioner’s decision released today.

Deputy Commissioner Dr Vanessa Caldwell found the nurses failed to notice “red flags” and demonstrated a “lack of care and skill” when looking after Mr A.

In 2018 Mr A, who was showing stroke-like symptoms was admitted to a hospital Emergency Department with sudden onset right-sided weakness, slurred speech, and a facial droop.

A CT scan revealed he was having a seizure and he was prescribed seizure medications levetiracetam and diazepam by a doctor.

The following morning Mr A had multiple seizures, often lasting 30 seconds. The two nurses looking after him, identified as Nurses B and C, agreed the medical team should review him.

After being reviewed, two doctors agreed that Mr A should continue to be administered diazepam and the dosage of levetiracetam be doubled to 500mg twice daily. Nurses B and C were told about these changes.

That same morning, when Nurse B went to retrieve the levetiracetam from the shelf, she couldn’t find it and asked Nurse C where it was, to which she replied it had been moved to the opposite shelf.

Nurse B went to the other shelf and saw a medication beginning with “lev” so grabbed it. Little did she know, it was in fact levomepromazine, an anti-psychotic medication.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell said the nurses demonstrated a "lack of care and skill" while caring for Mr A. Photo / Supplied

Nurse B later said she was not familiar with the drug and didn’t even know the ward stocked it.

Nurse C checked the name on the box and also mistakenly read it as levetiracetam, despite noticing the drug was smaller than she remembered, putting it down to a “change in medication”. The boxes were also different sizes and colours.

The two nurses noted they did not have enough of the drug to match Mr A’s required dosage so Nurse C went to get more at another ward. Nurse B noted that levetiracetam usually came in a 500mg bottle and not in 25mg ampoules - tiny glass jars.

After discussion, the nurses decided they would need 20 ampoules of the medication to make up the 500mg/5ml that had been prescribed, more than three times the recommended dose for a man of Mr A’s age, the decision said.

During this time a pharmacy technician who overheard the nurses discussing the dosage, questioned Nurse B, stating that the dosage level for levomepromazine - the anti-psychotic - seemed “wrong”.

However, Nurse B told her they had the right drug and dose, and it was administered to Mr A.

Nurse B then gave Mr A a bath and noticed he had become unresponsive to the people around him but put this down to the diazepam, once marketed as valium.

Less than an hour later the pharmacy technician raised her concerns about Mr A receiving what she thought was an unusual dose of levomepromazine to a colleague.

Soon after, another pharmacist found the missing levomepromazine and “began to panic” due to the high dosage missing. They went to ask Nurse C about it, informing her that Mr A had been given levomepromazine instead of levetiracetam.

The pharmacist said by the look on Nurse C’s face they could tell Mr A had been given the wrong medication.

His wife was informed, and Mr A was moved to the Intensive Care Unit (ICU) but sadly, three days later he passed away from pneumonia, due to an overdose of levomepromazine.

Following Mr A’s death, Nurse C stopped working as a nurse and told the HDC she regrets the “pain and sorrow” caused to Mr A’s family.

She also said nursing had “become a lot more time constrained and stressful over recent years”.

Nurse B provided an apology letter to Mr A’s family, outlining her “sincerest and heartfelt apologies” and took responsibility for her role in the tragic death. She had also undertaken various courses on medication errors.

Following a review of the care provided to Mr A, the unnamed former district health board found the root cause of the incident was that “the process for [an] independent double check [was] not followed correctly”.

The decision stated a double check of medication was when both staff checked the medication at the same time, often called out by one staff member and acknowledged by the other as opposed to both staff checking the medication independently.

Caldwell noted that both nurses failed to identify the errors in preparation despite multiple “red flags” and were therefore in breach of the Code of Health and Disability Services Consumers’ Rights.

“I accept there were circumstances which contributed to this error. I also consider it possible that confirmation bias played a role in successive opportunities to be alert to the error being missed.

“Even so, in my view, the nurses failed to comply with the DHB’s Checking IV Medication and Fluids - IV Manual by not checking adequately that they had the correct drug in the treatment room/pre-administration check.”

Caldwell made several recommendations for Te Whatu Ora including providing HDC with an update on any changes made as a result of the incident and undergoing an audit of all medication errors and compliance with policy over a three-month period.

Caldwell also recommended the evaluation of the “double-checking” process, consideration of the setup of medication storage, and implementing initiatives to improve checking compliance to reduce human errors.