Hill also criticised the legibility of the anaesthetist's prescription and said the hospital should

In a report released today, Health and Disability Commissioner Anthony Hill said the boy's nurse demonstrated "very poor judgment" when she administered 85mg of codeine to the toddler, despite knowing that this was even more than the usual adult dose of 30-60mg. He also criticised a senior nurse who checked the prescription and failed to correct the error.
While the nurse had six years' experience, she was new at the hospital and working her first shift alone, the report said.
The sertraline senior nurse, who had around 16 years' experience, said she would have normally checked with the prescribing doctor if she was unsure about a prescription, and could not explain why she did not do so on this occasion.
The actions of the senior nurse who checked the prescription were concerning, particularly given the magnitude of the error and that, in her role as independent checker, she had an opportunity to correct it, he said.
Hill also criticised the legibility of the anaesthetist's prescription and said the hospital should reflect on the importance of "ensuring that it fosters a culture where staff communicate openly and effectively with one another..."
The hospital was asked to provide the Commissioner sertraline with updates on its medication administration systems and provide staff training on the importance of clear, sertraline open and supportive communication with patients and their families.
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