Near miss... Clinical incident

[Isabella41]

I went round to mum's earlier to drop off her groceries. I normally go on fridays but went early as I'm out tomorrow night. I put the shopping away and when I went to put the milk in the fridge I noticed the butrans box was in there. I opened the box and realised a patch was missing. This box was in the locked meds box last night so I was also puzzled as to how it had ended up in the fridge.

Mum also uses patches for restless legs and they are kept in the fridge.

I asked mum how and why the butrans patches were in the fridge and where the missing patch was. Mum told me she had asked the carer to give her the patch for her restless legs and told her it was in the locked box. Without checking the box the carer handed it to mum. Mum's neighbour then stuck a patch on mum's back. This was in addition to the patch I had stuck on last Saturday. Mum then put the box in the fridge.

I went ballastic. Thankfully I took the second patch off and she was ok but I dread to think what might have happened if it hadn't been picked up as soon.

I rang the care agency and actually managed to speak to the owner. I explained what had happened and how concerned I was. She was also concerned. I told her mum was on supervised meds for a reason and there were good reasons why all meds were in a locked box. I told her there was little point in putting the meds in a locked box if all she had to do was ask the carer for the contents and have it handed to them.

She then rang me back. She said she had spoken to the carer who saw mum today and this carer was insisting she did not give the box of patches to mum. She reminded me that the code to the box was written in the care plan. I told her mum would not be able to do that. She can barely read anymore.

She also told me that they would not be prepared to administer the patches in any case.

I told the care agency owner that I would be changing the code and it would not be written down anywhere. If it then occurs again there will be no wiggle room as they can't then say it was mum or her neighbour.

I will also report it to the sw in the morning. It looks like I am going to have to commit to changing the patch each week.

Isabella

 

[Worried Woman]

Hi Isabella,

What a nightmare! Was the neighbour there at the same time as the care worker? Did you speak to the neighbour to find out her version? Does the leg patch go on your Mum's back as well? Seems strange not to notice that there was already a patch there. Do the patches look the same?

Gosh I'm asking a lot of questions - sorry! Just wondering how such a simple arrangement can become so difficult. Looks as if it could all end up with you again though. Care in the community....

 

[Onlyme]

I am sure you can feel a letter to the SW and mental health team coming on. If you hadn't gone round they could have had an elderly lady with an overdose on their hands. What would happen if you had been ill and not being part of her care as was agreed? It makes you shudder at the thought.

 

[SWMBO1950]

She said she had spoken to the carer who saw mum today and this carer was insisting she did not give the box of patches to mum

Of course she didn't!

I went round to mum's earlier to drop off her groceries. I normally go on fridays but went early as I'm out tomorrow night. I put the shopping away and when I went to put the milk in the fridge I noticed the butrans box was in there. I opened the box and realised a patch was missing. This box was in the locked meds box last night so I was also puzzled as to how it had ended up in the fridge.

Mum also uses patches for restless legs and they are kept in the fridge.

I asked mum how and why the butrans patches were in the fridge and where the missing patch was. Mum told me she had asked the carer to give her the patch for her restless legs and told her it was in the locked box. Without checking the box the carer handed it to mum. Mum's neighbour then stuck a patch on mum's back. This was in addition to the patch I had stuck on last Saturday. Mum then put the box in the fridge.

I went ballastic. Thankfully I took the second patch off and she was ok but I dread to think what might have happened if it hadn't been picked up as soon.

I rang the care agency and actually managed to speak to the owner. I explained what had happened and how concerned I was. She was also concerned. I told her mum was on supervised meds for a reason and there were good reasons why all meds were in a locked box. I told her there was little point in putting the meds in a locked box if all she had to do was ask the carer for the contents and have it handed to them.

She then rang me back. She said she had spoken to the carer who saw mum today and this carer was insisting she did not give the box of patches to mum. She reminded me that the code to the box was written in the care plan. I told her mum would not be able to do that. She can barely read anymore.

She also told me that they would not be prepared to administer the patches in any case.

I told the care agency owner that I would be changing the code and it would not be written down anywhere. If it then occurs again there will be no wiggle room as they can't then say it was mum or her neighbour.

I will also report it to the sw in the morning. It looks like I am going to have to commit to changing the patch each week.

Isabella

 

[Isabella41]

Patches look completely different. Neighbour has mental health probs - not dementia so not most reliable of witnesses. I can't see her having the reasoning skills to read the care plan, get the lock code and then open the box though. The 2 patches were clearly visible on mum's back. I can't prove it was the carer's fault as box code was written on front of care plan. The insinuation is someone other than the carer did it. The code will be changed on Saturday. The carers will have to phone me to get the code. There is only a regular rotation of about 3 or 4 so it will soon be known between them all.
I will of course be telling the sw tomorrow. It really doesn't bear thinking about what could have happened. Care in the community... don't make me laugh.
isabella

 

[lin1]

Hi
Thank heaven you had to go round when you did, being horrid IMO the carer would say that, but maybe it was the neighbour who mum asked who managed to find the code
sadly proving either is going to be darn near impossible, but I am pretty sure that that particular carer will be more careful infuture even if she was not responcible,

The other thing I am thinking It sounds very stange to me that, that lock medicine box was put in the fridge, rather than back in it's rightful place, so although I said earlier , the carer would say that, she could well be telling the truth and maybe something like this happened instead
Mum got the box out herself then got the neighbour to find the code in the care plan, the neighbour put the patch on mums back as mum told her thats where it should go, the neigbour or mum put the box in the fridge

I would not just tell the social worker what has happened but mums gp as well as he/she may be able to help also you are a patch down

I think all you can do now is damage limitation, which is what you are going

Could it be arranged that the district nurse change this patch on a regular basis

My mum had those Butrans patches I found them very good, as i was living with mum and the circumstances were very different to yours I put them on mum myself

I know on the box their was a place to record when patches needed to be changed, when mum whent into the hospice for respite, they also wrote on the actual patch in i think permamant ink, time and date it was applied

 

[Isabella41]

Sorry should have explained where the fridge comes in... the other patches for restless legs are supposed to be kept in the fridge hence why the butrans patches were put in the fridge by mum. Definetly not taken out of the box by mum as she wouldn't be able to line up the numbers to open the box. I don't think she even knew the code to the box was written down anywhere. For me the care assistant is the most likely person to have done this. But.. knowing and proving very different.
Isabella

 

[Isabella41]

Update:

Quite an interesting day..
I emailed the SW to tell her what had occured last night regards the patches. I got a short reply telling me the District Nurse would be in touch. Everyone is now playing pass the hot potato it seems. The DN phoned me early afternoon to hear what I had to say first hand. I reiterated the story back to her. Of course she was very guarded in what she would say on the whole matter. It basically comes down to knowing and proving. I know mum is in capable of reading a care plan, working out what "code 333" means and then using this code to unlock her medicines box. In fact if she could I reckoned she'd have done it a long time ago as there were many times she rang me telling me to come over and give her the tablets as the care assistant was late.

The DN went to tell me that as Butrans is a controlled drug the care agency would not be allowed to administer it. She said she would get the GP to phone me to discuss the options.

GP rang me an hour ago. She confirmed that care assistants were not allowed to dispense controlled drugs. If I wanted mum to remain on the patches I had a choice to make... I have to agree to be the one to change the patches week in.. week out or if I don't she will have to go back on the co-codomol. Talk about giving me options!! Interestingly she asked me if I had warmed the patch up to activate it before applying to the skin and if I held my hand against it for a few minutes. I had done neither. Mum has been reporting she is pain free and no constipation. She is eating better as well. However if the patch has not been activated and she is pain free it would seem to point to the pain being more in her head (imagined) rather than actual pain.

The GP also asked about the other patches mum was on. I told her that these are unsupervised and I really couldn't be sure if mum was using them as directed. She said they cost £80 per box so if she wasn't using them properly and needed them then they would be stopped. I don't have a problem with that. I told the GP I will note how many patches were used in a week and let her know.

Upshot of all this is that I find myself in the position of having no choice but to agree to monitor the pain patches and apply them as nescessary. Its the leeser of 2 evils. At least it means I am not getting numerous phone calls telling me she's constipated.

I have vague memories that grow dimmer by the day that I was once told mum was going to be cared for in the community as if I didn't exist. Hmm indeed!! I think I am a very useful invisble person.

Isabella

 

[loveahug]

Just reading this thread makes me ask a stupid question. How are you any more qualified to administer a controlled drug than the carers? Have you done a H&S course in patch applying or qualified as a DN? Or did you just read the instructions (so the carers can't read?). If a controlled drug can't be administered by a carer, it can't be administered by you either, so it's either the carers OR the DN surely

 

[Isabella41]

Just reading this thread makes me ask a stupid question. How are you any more qualified to administer a controlled drug than the carers? Have you done a H&S course in patch applying or qualified as a DN? Or did you just read the instructions (so the carers can't read?). If a controlled drug can't be administered by a carer, it can't be administered by you either, so it's either the carers OR the DN surely

Not stupid question but very logical one!! I am no more qualified to apply patches than the man who cleans my windows is. I can't work out why its ok for me (unqualified to do such things) to be in charge of applying and changing patches but the care assistants who presumably have OCN levels in health and social care possibly to advanced levels are not allowed to. Is there less of a chance of me getting it wrong.

I wasn't told by the pharmacist for example that getting into a hot bath wearing a patch is inadvisable as the warm water will dilate the skin and cause the active ingredient to be absorbed quickly. There have been cases of death as a result of such a thing happening. I also wasn't told that it is not essential that the patch must changed exactly on the same time/day each week. I could deviate by up to 72hrs with no ill effects. I wasn't told I needed to warm the patch up to activate it or that I needed to press it on the skin for a few minutes. I didn't do this so its entirely possible the patch has only had a placebo effect since last saturday. It was the GP who told me all the other stuff I've just mentioned.

I wonder if its a case that if I muck up and killed my mother I would be dealt with less harshly as I could claim ignorance but the care assistant would be treated differently as they are professional carers. It is an interesting point.

Incidentially they do give her prescirbed meds from a blister pack and there is some pretty potent meds in there. I can't work out how its ok for them to do this but not slap a patch on her back!!! There really is no logic with these people!!! I really do wonder if they are on a different planet than the rest of us.

Isabella

 

[Onlyme]

Brilliant, I love it.

If carers are not qualified then neither are we so everything should be the district nurses job. As if.

 

[Sue J]

It has always been my understanding re. these type of drug patches that they are activated by the patient's body heat, how else would you warm it up other than with your hands. And when someone has it on their back they lean against a chair which applies pressure.

I was surprised quite a number of years ago when an uncle, nursed at home, was prescribed morphine which his wife administered. When he died there was no procedure to collect or dispose of remaining substance Local pharmacist was happy to dispose of it though. Don't know what community regs there are re. controlled drugs but sounds like they haven't changed much.

 

[nitram]

"...I wasn't told by the pharmacist for example that getting into a hot bath wearing a patch is inadvisable as the warm water will dilate the skin and cause the active ingredient to be absorbed quickly. There have been cases of death as a result of such a thing happening. I also wasn't told that it is not essential that the patch must changed exactly on the same time/day each week. I could deviate by up to 72hrs with no ill effects. I wasn't told I needed to warm the patch up to activate it or that I needed to press it on the skin for a few minutes. I didn't do this so its entirely possible the patch has only had a placebo effect since last saturday. It was the GP who told me all the other stuff I've just mentioned...."

Did you read the patient information leaflet enclosed with the medication?

http://www.medicines.org.uk/EMC/pdfviewer.aspx?isAttachment=true&documentid=17008

 

[Isabella41]

It has always been my understanding re. these type of drug patches that they are activated by the patient's body heat, how else would you warm it up other than with your hands. And when someone has it on their back they lean against a chair which applies pressure.

This is what I thought too. Obviously I was wrong. Add in to the mix that the box of patches were in the fridge for a few hours yesterday and I have no idea whether this was detremential to them going forward. GP said nothing so I presume not.

Did you read the patient information leaflet enclosed with the medication?

Have to admit that no I didn't. I know the pharmacist personally so I always had the attitude he keeps me right with what I need to know. I was once prescribed something by a specialist for my own health issues and it was this same pharmacist who told me not to take it and went to tell me why. I guess in light of all the advice he's given me I reckoned he would tell if there was something special I needed to know about the patches such as warming them to activate them. As I said earlier the first I heard about this was from the GP earlier today.

Isabella

 

[jan.s]

So, what would happen if you didn't live close by? Would the poor lady have to suffer constipation for the rest of her days? It seems ridiculous that you can give it, or John, but not someone employed to care. Does it sound like a back covering exercise?

 

[Soobee]

This is what the District Nurse should be doing! Why won't they take responsibility?

Of course the other thing I was told about patches is that they tend not to be prescribed because they cost more than cocodamol.

 

[Isabella41]

Yes Jan. It very much looks like the only people who can have pain patches are those who can apply them without help or those who have family who will do it for them. So really the type of pain relief you are prescribed is not based on what works best for you but rather on who is available to administer the medication. I can't really get my head round that one!!

Mum has been calmer all week. No complaints of constipation and seems to be eating a bit more. She is not complaining her back is sore. Surely knowing all this should prove to the GP et al that the patches are the best fit for mum.

We plan on going on holiday for 2wks later in the year. I really have no idea who will sort the patches out then. I will warn the sw a couple of weeks in advance. I keep repeating their own assurances uttered at the discharge meeting that mum will be managed in the community as if I don't exist.

Isabella,

 

[Sue J]

This is what I thought too. Obviously I was wrong.

Well you weren't that wrong the patient information leaflet states press with the palm of your hand and count to 30 slowly.

Mum has been calmer all week. No complaints of constipation and seems to be eating a bit more. She is not complaining her back is sore. Surely knowing all this should prove to the GP et al that the patches are the best fit for mum.

And this shows it's working.

The senior people at the agency must be registered nurses and as such they should do it. It is a once weekly visit that should take not take long and if it is combined when other carers are there they can make sure your Mum is ready for the patch change and deal with any other problems. Failing that I would see it as a district nurse responsibility.

Why oh why don't they realise that keeping people pain free and comfortable eases many other symptoms and potential problems too. Hope you manage to get someone to take responsibility for it.