I have an adverse reaction to one of the drugs that is usually given for pain relief during a particular procedure. I had a meeting with the consultant anaesthetist pre operatively (in addition to standard pre op clerking) & he agreed that he wouldn't used that drug but that the alternative was less effective & I would need far more post operative pain relief than was usual. This was all agreed & written up in my notes & again in the surgery/anaesthetic notes & again on my drug chart - the comprehensive plan.
What happened after surgery? The nursing staff refused to administer the 'extra' pain relief, they said I shouldn't need it
Basically they couldn't be arsed to read the chart - dh & I pointed out the drugs plan & they still refused to administer it (the extra was written up as prn - i.e. when required - rather than on a schedule & they decided that gave them the right not to administer it). I insisted they call the anaesthetist, she mumbled something, wandered off & three hours later I still had not heard anything, no drugs, no anaesthetist, they sent the HCA around rather than a nurse when I tried to find out wtf was going on. When you are in really really bad pain after surgery a minute feels like an hour.
In despair dh called my mum who works, in a fairly senior clinical role, in the same hospital - she had the anaesthetist there within an hour of dh telling her what was going on & I got my pain relief. I self discharged the next day (was supposed to be in for three) - my GP prescribed the necessary drugs when I got home.
I imagine it happens all the time.