Where the consequences of an error are serious, rigorous procedures are needed.
When Ezra was transferred from the Forensic Psychiatric Hospital to Surrey Pretrial Services Centre (SPSC), the dosage of psychiatric medication he was prescribed was reduced. This caused Ezra significant mental distress, including strong suicidal tendencies.
Scared, and in urgent need of help, Ezra contacted us.
That same day, we launched an urgent investigation into the Provincial Health Services Authority (PHSA) administration of healthcare services to Ezra.
We questioned whether Ezra’s prescription had been adjusted when he was transferred and if yes, why. We were informed that when Ezra was transferred to Surrey Pretrial, a fax was sent from the Forensic Psychiatric Hospital with his dosage – 400mg every two weeks. When staff at Surrey Pretrial spoke with the hospital, they learned that Ezra had received a 200mg dose on the date of Ezra’s transfer. What was not properly understood was that this half dose had been a supplement to another half dose already provided. Misunderstanding the amount of the medication Ezra had received, and not properly following the instructions provided in the hospital’s initial fax, SPSC proceeded to provide Ezra with only a half dose every two weeks. This inadvertent dosage reduction accounted for the distress Ezra was experiencing.
Following our review, Ezra’s file was reassessed, the prescription error was identified and his medication dosage was adjusted back to the full 400mg.
The PHSA acknowledged that Ezra’s discharge summary from the hospital had not been properly reviewed thus causing the error. They explained that a change of practice had since been implemented and that healthcare staff are now required to confirm, by stamp, that each page of relevant documentation is reviewed upon receipt.
With Ezra’s medication being properly administered, and the PHSA establishing a new procedure to prevent a similar error from happening again, we considered the complaint settled and closed our file.
