Middlemore Hospital patient in 'overwhelming pain' after nurse accidentally mistakes pain-relief for fentanyl

A Middlemore Hospital patient says she was screaming in pain and throwing up after a registered nurse made a medication error that led to an overdose of fentanyl, a Health and Disability Commissioner report released on Monday found.

The woman in her fifties was receiving regular haemodialysis treatment which is a way of replacing some of the functions of your kidney if you have experienced kidney failure.

During the woman's regular visit to Middlemore Hospital in 2019, she was supposed to be given pain relief and anti-nausea medication before her dialysis began.

The woman also required the controlled drug fentanyl for her ongoing pain relief which is meant to be prepared and checked by a second nurse when the drug is removed by the dispensing machine.

However, since the second nurse was busy the nurse went ahead and administered the woman's anti-nausea medication before asking for help - but instead, the nurse mistakenly mixed up the anti-nausea medication with the fentanyl causing the woman to be given fentanyl at a greater dose than usual.

Fentanyl is an opioid medication used to treat severe pain. Its high potency means it requires careful preparation and administration.

The registered nurse discovered their error shortly afterwards and immediately told the woman and senior staff.

The ward doctor prescribed her naloxone to counteract the fentanyl but this resulted in a "cold turkey" withdrawal for the woman, causing her "significant pain" the report said.

"I remember be[ing] in severe pain all over my body, screaming and throwing my body all over the bed," the woman told the HRC. "I had gone into severe withdrawal symptoms. My pain in my body and legs were overwhelming ... [T]he naloxone IV [had] stripped me [of] all the iv fentanyl in my body and I was going into shock. The pain in my body was off the wall. I just thrashed around while nurses tried to hold me down."

The woman was observed to be significantly distressed, but this was not documented adequately, the report also found.

The Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the registered nurse and Counties Manukau District Health Board (CMDHB), now Te Whatu Ora Counties Manukau, in breach of the Code of Health and Disability Services Consumers' Rights.

Dr Caldwell said the registered nurse breached the Code for multiple issues, including failing to prepare the fentanyl immediately, incorrectly administering the fentanyl, not monitoring respiratory rate and providing insufficient documentation.

Te Whatu Ora was found to have breached the Code due to the practice of its nursing staff on the dialysis unit that inappropriately removed medication from the dispensing machine before it was required, and because its staff dud not adequately document the woman's care and observations.

"Fentanyl is a strong opioid that requires careful preparation and administration owing to its potency," Dr Caldwell said. "The [registered nurse] had a duty of care to the patient to prepare the fentanyl safely, in accordance with CMDHB's Intravenous Opioid Protocol."

Dr Caldwell made a number of recommendations for Te Whatu Ora Counties Manukau, including providing a written apology to the woman, undertaking a code of compliance for drug policies by nursing staff and providing training and education to clinical staff in the dialysis unit.

"Since the complaint, Te Whatu Ora has made a number of changes including mandating that staff no longer remove medication from the dispensing machine before patients are physically in the unit, and for medication to be checked out as close to administration time as is practically possible," the report said.

The registered nurse has since undertaken training including practising the "5 Rights" before administrating medication.

"I note that the registered nurse in question has made changes to his practice to, 'ensure that it is safe, competent, professional'," Dr Caldwell said.