Assessment 2 Question 1: This case study is a summary of where a medication error contributed to the cause of death. It is a real life incident of a coronial investigation obtained from public documents. A document becomes public once the coronial investigation process has been completed and closed. All individuals and facilities are de-identified. Some details have been removed which was deemed unnecessary for this Assessment piece. CLINICAL SUMMARY Mrs C was a 69-year-old female with a complex medical history of stroke with a residual left side weakness and ongoing risk of aspiration, atrial fibrillation, and insulin-dependent diabetes mellitus. She was more recently diagnosed with a suspected left ear tumour. Mrs C had a planned admission to a metropolitan hospital for a biopsy. Mrs C was commenced on oral antibiotics (ciprofloxacin) after the biopsy results suggested an infection. One day after the procedure, her oxygen saturation levels dropped and staff suspected she had aspirated. A nasogastric tube (NGT) was inserted but was pulled out by Mrs C a day later. Despite advice from healthcare professionals about the risk of further aspiration and sub-optimal oral nutrition, neither Mrs C nor her immediate family would consent to the reinsertion of a NGT. Three days later, following another episode where Mrs C’s oxygen saturation levels dropped, x-rays showed acute pulmonary oedema with right lower lobe consolidation and an ECG demonstrated Mrs C had rapid atrial fibrillation. For these reasons, Mrs C was transferred to the Intensive Care Unit (ICU), where a NGT was re-inserted. The nurse-in-charge (NIC) left instructions that Mrs C’s oral ciprofloxacin ought to be crushed and administered through the NGT tube. Later that same evening, blood tests were required, and the nursing staff realised that Mrs C’s evening medications, including the oral ciprofloxacin and intravenous frusemide, had not yet been administered. The nurse (RN. R) looking after Mrs C was asked to take the bloods via a peripherally inserted central catheter (PICC), and to administer the medications. As she had not had prior experience of PICC lines, she was supervised by another nurse (RN. C). RN. R was instructed to crush the ciprofloxacin to enable NGT administration, but then drew the paste into a standard sized non-luer lock syringe even though she intended to administer the medication via the NGT, which required a larger nozzle. RN. C drew up the frusemide and both medications were placed into a kidney dish. At the bedside, RN. R took blood from the PICC line, and administered the intravenous frusemide. The NIC was present at the time, attending to Mrs C’s NGT feeding. The NIC informed RN. R that medications administered via a PICC needed to be drawn up in a luer lock syringe. RN. R returned to the drug room and transferred the crushed up ciprofloxacin into a luer lock syringe, injecting it into the PICC line. A short time later, Mrs C became cyanosed and hypoxaemic, then unresponsive. Since Mrs C was subject to a NFR (not for resuscitation) order, a code blue was not called. She was pronounced deceased soon after. An autopsy performed later found foreign material in the vessels of the brain, lungs and heart. INVESTIGATION Looking primarily at the circumstances in which Mrs C had died, the coroner at inquest focussed on several issues. 1 of these specifically included: • The adequacy of remedial measures taken by the health service to minimise the risk of such errors in drug administration. The Director of Medical Services gave evidence that a number of safety measures had since been implemented by the hospital following an internal investigation. .