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Medication mix-up prompts call for safeguards

Mary Jane Lawrence's elderly parents had their medications mixed up twice by home care workers. Lawrence is asking for better procedures to be in place to ensure it doesn't happen to her parents or anyone else again.

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Mary Jane Lawrence's elderly parents had their medications mixed up twice by home care workers. Lawrence is asking for better procedures to be in place to ensure it doesn't happen to her parents or anyone else again.

An 86-year-old Brandon woman was rushed to hospital this week after a home-care worker mixed up an elderly couple’s medication — the second time in a year they have had their meds reversed.

Their daughter, Mary Jane Lawrence, wants to see more safeguards in place to prevent cases of mistaken medication.

On Wednesday evening, a health-care aide reversed the medication of Lawrence’s mother and 87-year-old father, giving her mother an unnecessary dose of Ativan (a high-potency anti-anxiety pill), prostate medication and a sedative.

Lawrence’s mother realized the mistake prior to taking her husband’s heart medication, which could have been lethal.

The elderly couple wish not to be named.

Lawrence rushed her mother to the Brandon Regional Health Centre, along with her father, to wait for nearly three hours before seeing someone in the ER, she said, while her mother’s wrong dose of medication caused sweats, dizziness and vomiting.

"We were in the waiting room and (she) was sick in cardboard containers," Lawrence said. "It’s embarrassing."

By the time the couple saw a doctor, there was little more the hospital could do since much of the medication was out of her system. She is back home now recovering.

In the year-and-a-half the couple has been using home-care services, this is the second time their meds have been accidentally swapped by an aide.

In the first case last winter, Lawrence’s father had been given his wife’s medication — pills for diabetes and chemotherapy — as a result of a home-care worker error.

Lawrence insisted she’s not blaming the staff.

"There’s no complaints with the staff," she said. "The staff are very good with them.

"But we are human and mistakes are being made, and we need to find a solution."

Aides are not assigned to specific homes and Lawrence’s parents receive aid three times a day. Appointments are generally less than 10 minutes long.

According to Prairie Mountain Health CEO Penny Gilson, there were 517 reported home-care incidents in 2013 across the Prairie Mountain Health region, which has more than 1,000 clients.

Of those incidents, 247 were medication-related, but that could include anything from botched paperwork to giving the wrong medication.

"Our home-care service, like any other service, is service provided by humans and as nobody is perfect, we do unfortunately have errors happen," Gilson said.

Protocols are in place to avoid mix-ups, such as a mandatory triple check policy and storing the client’s medication in pre-packaged blister packs labelled with names.

Like similar incidents within a hospital, incident reports are filled out by home-care workers and their superiors, triggering an investigation.

The health authority walks a fine line when it comes to punishment. If workers fear they will be fired every time an incident such as the one involving Lawrence’s parents, Gilson said none would be reported.

She wouldn’t specify the number of mistakes an aide must make before getting fired.

"We want staff to report incidents because if you set out to investigate within a blaming context, we run the risk of staff not reporting," she said.

"We want to know about it."

Services provided by home-care aides within the health region include helping with medication administration, assistance with daily living (including bathing and going to the washroom), physiotherapy and occupational therapy, and routine laundry and linen service.

According to Gilson, the province’s aides must complete at least 10 months of training before they start the job, and receive annual reviews and periodic education.

While some registered nurses work within the home-care program, Gilson said the "vast majority" are designated as home-care attendants.

Lawrence was able to drive her parents home after the hospital visit, but Gilson couldn’t say if the $455 ambulance bill would land on the client if they are hospitalized as a result of a home-care worker error such as this one.

"I don’t think I can speak to that because it would be highly dependant on circumstances and our review."

» gbruce@brandonsun.com

Republished from the Brandon Sun print edition January 18, 2014

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An 86-year-old Brandon woman was rushed to hospital this week after a home-care worker mixed up an elderly couple’s medication — the second time in a year they have had their meds reversed.

Their daughter, Mary Jane Lawrence, wants to see more safeguards in place to prevent cases of mistaken medication.

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An 86-year-old Brandon woman was rushed to hospital this week after a home-care worker mixed up an elderly couple’s medication — the second time in a year they have had their meds reversed.

Their daughter, Mary Jane Lawrence, wants to see more safeguards in place to prevent cases of mistaken medication.

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