This report outlines the investigation conducted by the Health Ombudsman into the adequacy of systems in place at Friendly Society Private Hospital to ensure the appropriate administration of medication to patients, procedures for responding to adverse drug reactions and procedures for incident reporting.

The investigation commenced as a result of a complaint the Office of the Health Ombudsman received about the treatment provided to a patient by nursing and medical practitioners in October 2013 and July 2014. The complaint prompted a systemic investigation into the concerns raised about the circumstances in which the patient could be administered medication on two separate occasions when she had a known allergy to the medication, and the procedures in place to respond to, report on, and address the incident.

The scope of the investigation into the care provided by Friendly Society Private Hospital was to determine:

1. Whether the hospital’s responses to the adverse drug reactions were timely and appropriate.
2. Whether the hospital had appropriate protocols and procedures relating to administration of medication.
3. Whether the hospital had appropriate protocols and procedures relating to adverse drug reactions.
4. Whether the hospital had appropriate protocols and procedures relating to incident reporting.

In the course of the investigation, the office requested and received the following documentation from the hospital:

• administration of medication policy
• adverse drug reactions—prevention and reporting policy
• clinical documentation policy
• clinical handover policy
• incident reporting policy
• risk management policy
• root cause analysis report relating to the patient
• new graduate clinical orientation program
• staff attendance records for policy update training.

Following a review of the documentation provided, the office requested and received the following additional documentation:

• minutes from the Medical Advisory Committee (dated 13 October 2014)
• annual mandatory medication safety training package
• allergic reaction case-study and presentation notes (training)
• employee attendance record for patient allergic reaction case-study training
• online pharmacology training report (staff responses to allergy question)
• medication safety presentation package
• progress report on the hospital staff completion rates for medication safety training package.

The office also requested and received clinical advice from a registered nurse.

After reviewing and analysing the evidence, the Health Ombudsman determined that human error and poor decision making were the main factors leading to the administration of a medicine to a patient who had a known allergy to the medication. There was no evidence of systemic issues at the hospital, including procedural or policy failures, that could have or did contribute to the incidents.

Overall, the Health Ombudsman was of the view that no further action should be taken under the Health Ombudsman Act 2013 as the identified issues had been appropriately resolved or finalised through the outcome of the complaints against the individual registered health practitioners involved with the patient’s care.