Deceased
Janet Ann Cook
Demographics
79y, female
Date of death
2015-09-30
Finding date
2019-06-21
Cause of death
multi-organ failure as a result of ischaemic and valvular heart disease with urinary tract infection complicated by the effects of hydromorphone
AI-generated summary
Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 September 2015. The error occurred despite policies requiring identification verification. Enrolled nurse Csorba failed to pay proper attention during medication administration. While registered nurse Bottger likely read out patient identification from the wristband and Csorba responded 'yep', Csorba was inattentive and failed to verify the patient's identity visually despite having nursed both patients that morning and knowing they were physically distinct. The medication was absolutely contraindicated in this frail elderly, opiate-naïve patient with liver impairment. The coroner found the error resulted from human inattention despite adequate policies and procedures, with Csorba's subsequent evidence at inquest being unreliable and self-serving.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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