Download the pdf version of this decision. - Health and Disability ...

Opinion/00HDC00231
with a continuous flow set and was not regulated with either a burette or an infusion pump.
My anaesthetist advisor noted that this was in accordance with Dr E’s preference sheet,
which stated that he required a Buretrol set only in children under the age of three years.
My anaesthetist advisor considered that this practice was acceptable, as discussed above.
Mr F informed me that at the time it was normal practice for the anaesthetic nurse to
assemble the IV line with a continuous flow set unless otherwise ordered by the doctor or if
the child was an infant.
Mr F set up the IV drip in accordance with hospital policy and nursing guidelines, according
to Dr E’s preference. There is no evidence that Miss C was administered more than the
prescribed amount of dextrose saline while in the care of Mr F. In my opinion, Mr F
provided nursing services to Miss C with reasonable care and skill, and in compliance with
relevant standards, and did not breach Rights 4(1) and 4(2) of the Code.
Opinion: No Breach – Ms H
Rights 4(1) and 4(2)
In my opinion Ms H did not breach the Code.
Ms H was involved in Miss C’s care on her transfer from theatre to the recovery room. On
transfer, Dr E prescribed Miss C’s IV flow rate at 80mls/hr. Both my advisors informed me
that monitoring the drip at the prescribed rate is a nursing responsibility.
My anaesthetist advisor considered that once a patient leaves the theatre setting, and no
longer has one-on-one care, it is easier, safer, and more accurate to change from a
continuous flow rate, to other measures to regulate the flow of IV fluid. However, my
nursing advisor informed me that the recovery room can be considered as part of the theatre
setting because of the close monitoring of the patient (one-on-one) that occurs there. In this
respect, I accept that it was reasonable for the nurses in the recovery room (Ms H and Ms
G) to continue manually regulating the IV flow with a continuous flow set.
Ms H assisted with the immediate preliminary procedures that all patients receive while in
recovery. She recalled checking the intravenous line and altered the flow rate by reducing it
to accommodate the requirements charted by Dr E. Ms H was then required to receive
another patient from the operating theatre and had no further involvement with Miss C.
The evidence suggests that Miss C received the appropriate amount of fluid while in the
care of Ms H. Accordingly, in my opinion Ms H provided nursing services to Miss C with
reasonable care and skill, in compliance with relevant standards, and did not breach Rights
4(1) and 4(2) of the Code.
18 June 2002 25
Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and
bear no relationship to the person’s actual name.