According to the report, the medication would actually have been given to another person at the accommodation.
The woman had a deteriorating health condition after the wrong medication, which was discovered the next day.
She became powerless, blunted and had her heart rate lowered.
During the day, the woman's condition was followed up, and in the end she is said to have been completely restored.
The investigation of the incident shows that the accommodation in Enköping developed an incorrect working method regarding the handling of medicines when, among other things, unmarked medicine cups were used when handing over medicines.
The management must have known about the problems before.
Municipality: Very serious
Anna-Karin Bye, medically responsible nurse at Enköping Municipality, writes in an email to SVT that she takes the incident very seriously because a drug confusion can lead to great suffering.
- I do not think the staff want to make mistakes but they want to follow the routine, but have here on their own initiative developed a way of working that is not safe.
The management of the accommodation had noticed this and put in place measures to secure it.
Unfortunately, they did not fully arrive before this serious event had time to occur, she writes.
According to Anna-Karin Bye, several measures have been taken - among other things, personal medicine cabinets must be installed for each individual resident.