Senior died after nurses gave him another patient's medication, report finds

An 85-year-old Gatineau, Que., man died in hospital after he was accidentally given methadone, which had been prescribed to another patient, said a coroner's report released Tuesday.

William Madaire was admitted to the hospital in October 2017 because he was falling and experiencing confusion. He died 11 days later after he was given the wrong medication, Outaouais coroner Pascale Boulay wrote in her report. 

"It's a tragedy, [it] should not have happened," Boulay said in an interview Tuesday.

The report outlines how a series of medical errors contributed to Madaire's death.

A nurse mistakenly transcribed a methadone prescription from the chart of a female patient who used to be in Madaire's room, and then, without checking his identity, an auxiliary nurse gave Madaire five milligrams of the methadone. 

Boulay said nursing staff failed to look beyond the room number to identify the patient.

"This is nursing 101 — making sure that you actually verify the identity of the person you are giving medication to," Boulay said.

"In this case, [they] relied only on the room number. [They] didn't even make sure it was the right person."

The report said the methadone did not kill Madaire, but the opioid did contribute "in a significant way" to the development of pneumonia.

Boulay said the methadone led to Madaire losing consciousness for two days, suppressing his central nervous system, respiratory system and his swallowing reflex. He should never have been given the medication, she said.

Recommendations outlined

The report includes four recommendations for the Centre intégré de santé et des services sociaux de l'Outaouais (CISSSO), Quebec's professional association of nurses and the province's professional association for auxiliary nurses.

In the report, Boulay recommended that CISSSO direct staff to follow best practices on administering medication and develop a complete nursing treatment plan for each patient. 

The coroner's report also asked for the nurse and auxiliary nurse to be referred to their professional bodies for investigation.

The professional organizations for nurses and auxiliary nurses declined to comment Tuesday. 

The Quebec Coalition for Patient Protection said Madaire's case is tragic and a clear example of medical errors and omissions compounding.

"We're not talking about adding some more rules," said Paul Brunet, president of the coalition. "We're talking about reminding personnel professional nurses and others as to what is the job about and make sure that you're treating the right patient with the right medication."

Brunet said medication errors are among the top errors in the province's health care system.

"I beg the authorities to remind them of procedures, to remind them of instruction," he said. 

In a statement, CISSSO said it has read the coroner's report and will implement its recommendations.