A nurse who gave a critically-ill patient the wrong drugs is facing disciplinary action.
The Health and Disability Commissioner has investigated the case which happened in late 2010 at an unnamed hospital.
The 69-year-old man, who had cancer and had suffered a heart attack, was given the wrong drugs and died two days after being admitted.
The commissioner's report says the man's condition deteriorated and the senior nurse did not recognised the significance of this or seek a medical review.
The nurse obtained the man's prescribed medication, but accidentally attached the sheet to the file of another patient.
As a result, she mistakenly believed that medications listed on the other patient's file had been prescribed for the man.
The nurse administered three of the other patient's medications to him but, upon realising this, did not report the error or ask for a doctor's assessment.
The man died within hours. The nurse admitted her medication error two days after the death to the district health board, which is not named in the report.
A complaint was lodged by the Nursing Council and the nurse is no longer practising.
Health and Disability Commissioner Anthony Hill told Radio New Zealand's Checkpoint programme on Monday the nurse has been referred to the Director of Proceedings who will decide if there will be further action.
Mr Hill says the nurse was unprofessional, as she did not disclose the error immediately when she recognised it.
