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Health and Disability Commissioner
responsible for counting the drip rate on a regular basis and changing it to the
required rate so that the correct amount of fluid was delivered to [Miss C].
• [Miss C] was received in Recovery by [Ms G] who states in her letter to the
Commissioner that she monitored [Miss C] and manually adjusted the drip rate to
ensure it was running at the prescribed rate. As [Mr O’s] letter to the Commissioner
states that the ward nurse who received [Miss C] from Recovery estimated that
approximately 200mls had been administered in theatre and recovery, it is my
opinion that [Ms G] monitored [Miss C] and the drip in a manner that met
professional standards of practice. It is often necessary during an operation to
administer fluid at flexible rates to maintain blood pressure and to administer drugs
and as only 200mls had been used it would seem that for the hour [Miss C] was in
recovery she was administered the appropriate amount of fluid.
• [Miss C] was returned to the ward at 11.30am approximately and responsibility for
her care was taken by Ms I who notes in her letter to the Commissioner that she did
not check the drop rate as ‘… I assumed it to have been set in recovery …’.
Managing intravenous infusions (drips/drops) at the prescribed rate is a nursing
responsibility and because many factors can affect the flow rate, the drip does not
necessarily continue to run at the rate originally set. The nurse must therefore
monitor drips frequently (15-30 minute intervals) to ensure that the fluid is running
at the intended rate (Brunner and Suddarth). In my opinion [Ms I] did not exercise
reasonable skill or care in the monitoring and regulation of [Miss C’s] drip and
therefore did not meet NZ Nursing Council standards in relation to performing [Miss
C’s] care in a way that was safe (NZ Nursing Council, 1999, 4.5, 4.6, 4.7, 4.8).
• When the afternoon shift commenced at 1445 hrs, [Ms K] assumed responsibility for
[Miss C’s] care. [Ms K] notes in her letter to the Commissioner that she commenced
the third litre of fluid at 1745 hrs. This meant that [Miss C] had received 2 litres of
fluid over seven and a half hours approximately when [Dr E] had instructed the
nurses that [Miss C] was to receive 80mls of fluid an hour. [Ms K] notes, ‘… that it
was not obvious to me that this was the third bag of fluid … I also failed to chart it
on the fluid balance chart’. It is my opinion therefore that [Ms K] did not exercise
reasonable skill or care in the monitoring and regulation of [Miss C’s] drip and
therefore did not meet Nursing Council’s standards of ensuring effective and safe
nursing care for [Miss C] (NZ Nursing Council, 1999, 4.5, 4.6, 4.7, 4.8).
• [Mrs M] took over [Miss C’s] care at 1745-1800hrs and provided one on one
nursing care. She noted that the drip was going fast so turned it down and requested
an infusion pump. There was a delay in receiving this and by 2030hrs when the
Cogentin infusion was ordered [Miss C] had received another 700mls
(approximately) of fluid over 2hrs and 45 minutes. This means that over that time,
[Miss C’s] drip was running at approximately 250mls per hour. It is my opinion
therefore that [Mrs M] did not exercise reasonable skill or care in monitoring and
regulating [Miss C’s] drip and therefore did not meet Nursing Council’s standards of
14 18 June 2002
Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and
bear no relationship to the person’s actual name.