Reference no: EM133227075

Question - Mr Rai Thapa , 71, was admitted to City Hospital on Jan 15, 2022, with renal complications, liver and heart failure. He was allocated to room 29. Mr Cooper was prescribed Metformin 500mg BD and Actrapid as per the sliding scale chart.

In room 29 was Mr Ram Thapa. Ram was an insulin dependant diabetic and required both subcutaneous Novorapid 48 units mane, a drug kept in the fridge in the medication room, and 10 units Lantus subcutaneously mane.

There were two nurses present at the bedside when Mr Rai was mistakenly administered Novorapid 48 units and Lantus 10 units subcutaneously, after which he died nine days later.

One of the nurses present was an enrolled nurse - Mr Sameul. Sameul was primarily responsible for the care of both Mr Rai and Mr Ram, as well as two other patients in the ward. Sameul, who has since been the subject of an inquiry by AHPRA and the coroner's court, was adamant that a registered nurse (Ms Bailey), who had accompanied him, had in fact administered the medication to Mr Rai without calling out the identity numbers first.

Sameul also claimed that he did not see the medication being given because he was busy looking at the patient chart. Nikita, who administered the medication, stated that she did in fact call out the patient's name, date of birth and MRN/URN number.

An expert witness told the inquiry that the medication error "shortened" Mr Rai life expectancy and that the dose of insulin would have "flattened him"-as he was a frail elderly patient who had liver impairment.

The coroner stated that "it is no coincidence that Mr Rai's health dramatically deteriorated in the hours following the administration of the insulin," finding that the medication error was consistent with a "state of inattention." The coroner found that "the Enrolled nurse was in the room along with the other nurse; however, it is apparent that had he been concentrating, he would have identified Mr Rai as the wrong patient, having nursed both Mr Rai and Mr Ram that morning." The coroner further added, "it is consistent with that state of inattention that the enrolled nurse would also have failed to listen carefully to the identification as read out from the wristband."

Identify scope of practice issues that relates to the case study.

Identify the legal aspects of the case with reference to legislation.

Identify the ethical aspects of the case in relation to nursing codes and standards.