Decision Report 201305723

Summary

Mr C was admitted to the Western Infirmary with symptoms of nausea and vertigo. He was kept in overnight and discharged the following day, with a prescription for medication to take on an 'as required' basis to relieve his symptoms. As the hospital pharmacy was closed, he was given a small amount from the ward's supply until he could get his own prescription, but was given the wrong medication. In responding to Mr C's complaint, the board acknowledged that he had been given the wrong medication in error and apologised.

Mr C complained to us because the board had not fully addressed his concerns that a nurse had advised him to take the medication three times a day for three months, instead of on an 'as required' basis, and instructed him on the use of a spray he already used. He also said that the medication might have been intended for another patient, which could have had serious consequences for them. In responding to our enquiries, the board acknowledged that they should have provided Mr C with a fuller response. They explained that they had put an action plan in place to highlight to all staff the importance of ensuring safe medication practice.

We took independent advice on this complaint from one of our medical advisers. He did not think it likely that there was a mix-up with another patient, but rather that there had been a basic dispensing error. He noted that the frequency advice appeared to relate to the incorrect drug that was provided, and confirmed that there would have been no serious consequences had Mr C taken that drug. In relation to the advice on using the spray, the adviser noted that it was common for a hospital to prescribe medication that forms part of a patient's usual prescription, and that they may just have been making sure his medication supply was complete.

As Mr C was given the wrong medication and advice, we upheld his complaint. However, as we were satisfied that in this instance the drug error was not serious in nature, and that the board had acknowledged the error, apologised and taken steps to try to prevent this happening again, we did not need to make any recommendations.