In another saddening reminder of the importance of  addressing the problem of medication error, The New Zealand Herald recently reported on the case of an elderly man who was experiencing seizures, only for nurses to provide him the incorrect medication.

As a consequence of the overdose, the patient unfortunately passed away several days later.

Levomepromazine mistaken for levetiracetam

The newspaper serving the Auckland area of New Zealand reported that the man, in his 90s, was administered three times the recommended dose of levomepromazine, after the drug had been mistaken by two nurses for his prescribed medication, levetiracetam.

Following the patient’s death three days later, one of the nurses resigned, stating that she had found it difficult to acknowledge the mistakes she and her co-worker had made, and which had “caused the death” of the patient.

A Health and Disability Commissioner (HDC)’s decision, released in May 2023, referred to the patient as “Mr A”. Dr Vanessa Caldwell, Deputy Commissioner, found that the nurses had not noticed “red flags”, and showed a “lack of care and skill” when looking after Mr A.

The tragic event occurred in 2018, when Mr A was admitted to a hospital Emergency Department with stroke-like symptoms, including sudden onset right-sided weakness, a facial droop, and slurred speech.

It was discovered through a CT scan that the patient was experiencing a seizure, and a doctor prescribed him levetiracetam and diazepam.

The next morning, Mr A experienced multiple seizures, with some of these lasting 30 seconds. The two nurses responsible for his care, identified as Nurses B and C, agreed that he should be reviewed by the medical team.

Following this review, two doctors agreed that diazepam should continue to be given to Mr A, and that the levetiracetam dosage should be doubled to 500mg twice a day. Nurses B and C were informed of these changes.

However, when Nurse B sought to retrieve the levetiracetam from the shelf that morning, the medication was missing, and she asked for information on its location from Nurse C, who told her it had been moved to the opposite shelf.

Looking to the other shelf, Nurse B spotted, and took, a drug with a name beginning “lev”. But she did not realise this was in fact the anti-psychotic medication, levomepromazine.

Nurse B later stated that she was not familiar with this medication and wasn’t even aware of it being in the ward’s stock. Checking the name of the drug on the box, Nurse C also mistakenly read it as levetiracetam.

A mistake that had tragic consequences

The two nurses observed at the time that they lacked sufficient quantities of the medication to match the dosage required by Mr A. Nurse C therefore went to another ward in search of more of the drug.

After discussing the matter, the two nurses decided that 20 ampoules of the medication would be needed in order to make up the prescribed 500mg/5ml amount. However, the HDC’s decision said this was more than three times the recommended dose for a man of Mr A’s age.

The drug was subsequently administered to Mr A. However, when Nurse B then gave the patient a bath, she noticed that he had become unresponsive to the people surrounding him.

Less than an hour following this, the pharmacy technician voiced concerns to a colleague about Mr A receiving what she believed to be an unusual dose of levomepromazine.

When another pharmacist then discovered the missing levomepromazine, it was realised that this was the drug that had been given to Mr A, instead of levetiracetam.

The patient’s wife was informed, and he was transferred to the Intensive Care Unit (ICU). Sadly, just three days later, he died from pneumonia.

“Pain and sorrow” over the heartbreaking event

After Mr A’s death, Nurse C stopped working as a nurse. She said to the HDC that she regretted the “pain and sorrow” caused to Mr A’s family due to the tragic incident.

She was also quoted as saying that nursing had “become a lot more time-constrained and stressful over recent years”.

An apology letter was provided to Mr A’s relatives by Nurse B, who expressed her “sincerest and heartfelt apologies”, and said she took responsibility for her role in the patient’s passing. She had also undertaken a number of courses on medication errors.

The unnamed former district health board said, after a review of the care Mr A received, that the incident’s root cause was that “the process for [an] independent double check [was] not followed correctly”.

The decision said that a double check of medication entailed both members of staff checking the drug at the same time – often called out by one staff member, with the other acknowledging it – as opposed to both staff carrying out independent checks of the medication.

Dr Caldwell said that both nurses were in breach of the Code of Health and Disability Services Consumers’ Rights, having failed to spot the mistakes in preparation despite several “red flags”.

A number of recommendations were made by Dr Caldwell for the Te Whatu Ora (Health New Zealand) agency. These included updating the HDC on any changes made arising from the incident and carrying out an audit of all errors made in relation to medication over a three-month period.

Dr Caldwell further called for the “double-checking” process to be evaluated, alongside consideration of the medication storage setup, and the introduction of initiatives to optimise checking compliance, in order to reduce the scope for human error.

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