Medication Safety and Hospital Referrals

1 May 2007

Medication Safety and Hospital Referrals

A chain of errors at Auckland City Hospital in August 2004 led to an elderly patient receiving incorrect medications that hastened his death.

Health and Disability Commissioner Ron Paterson has today released a report on the care provided to an 82-year-old man, Mr B. A mix-up in GP referral documentation led to Mr B receiving the wrong medication, which was incorrectly prescribed based on the medical records of another patient.

In his report, Mr Paterson notes that Mr B's death was the end result of systemic weaknesses in the referral and prescribing processes at Auckland City Hospital. Mr Paterson states:

"Mr B's case highlights the risks associated with a hospital's failure to reconcile the medications for a given patient. There needs to be a comprehensive system for medication reconciliation."

"Hospital staff need to ensure that a complete and accurate list of a patient's current medication is compiled, checked and reconciled to ensure that the patient is prescribed appropriate medication at the appropriate dose, in secondary care."

"The series of events that led to Mr B's death could occur at other hospitals. There is therefore a need to highlight these systemic weaknesses to other District Health Boards."

Key facts from the report

82-year-old Mr B was referred to Auckland City Hospital by his GP on 10 August 2004. He had peripheral vascular disease, bilateral lower limb amputations and diet controlled type II diabetes. His GP was concerned about his ability to cope at home, and an ulcerated painful right stump.

Mr B's GP faxed a one-page referral to the hospital. Another patient's referral also arrived by fax and included three pages of unidentified patient information. Unfortunately, once the referral was received at the hospital, the three pages of medication and other information relating to the other patient were mistakenly attached to the back of Mr B's referral. The other information related to a patient with similar health complaints to Mr B's.

The documentation was then forwarded to the ward where Mr B was admitted. The house surgeon admitting him relied on the referral documentation and prescribed oral diabetic medications, metformin and glipizide, which were not part of Mr B's usual drug regime.

The mistake was discovered when, having been administered the medication prescribed, Mr B became unstable and the house surgeon tried to contact his doctor to ascertain whether he had had similar episodes in the past.

Attempts were made to stabilise Mr B's condition, however they were unsuccessful and he died on 14 August 2004.
1. A Coroner's inquest was held and it was found that Mr B died of hypoglycaemia, renal failure and metabolic acidosis due to the administration of metformin and glipizide. I am advised by the Royal New Zealand College of General Practitioners that the particular problem with the MedTech32 software programme has been resolved in light of this case.

Commissioner's findings

2. Mr B's case highlights the risks associated with a hospital's failure to reconcile the medications for a given patient, and the need for a comprehensive system for medication reconciliation.

Hospital staff need to ensure that a complete and accurate list of a patient's current medication is compiled, checked and reconciled to ensure that the patient is prescribed appropriate medication at the appropriate dose, in secondary care.

3. Although this case related to the handover of a patient from primary to secondary care, the risks are the same when a patient is transferred between hospital wards or discharged from hospital back to primary care.

4. As the average length of stay of a patient in hospital reduces, there is very little time for physicians, nurses or pharmacists to become involved in medication counselling, and so any process for reconciliation needs to be streamlined and effective.

5. The series of events that led to Mr B's death could occur at other hospitals. There is therefore a need to highlight these systemic weaknesses to other District Health Boards.

6. The situation where various independent GP software systems have been developed without reference to the need for patient safety also needs to be addressed.

Commissioner's decision

In light of the significant investigation already undertaken into this complaint by the Auckland District Health Board, ACC and the Office of the Health and Disability Commissioner, together with the steps already taken by the Auckland District Health Board to remedy the situation, the Commissioner decided that further investigation was not warranted as it would be unlikely to elicit any further useful information.

The Commissioner does, however, believe that there is a need for more work, at a national level, to develop a co-ordinated and consistent approach to medication reconciliation. The case has been brought to the attention of the Minister of Health with a recommendation that a national policy for medication reconciliation be developed and implemented, after trialling a funded initiative at an individual District Health Board (to establish a system that works well). The Commissioner has recommended that the new Quality Improvement Committee and the National Safe and Quality Use of Medicines Group be charged with oversight of this task.

A copy of the report will be posted on the Health and Disability Commissioner's website (www.hdc.org.nz/files/HDC/Opinions/05HDC17139) on Tuesday 1 May.

Background information

The Code of Health and Disability Services Consumers' Rights is a regulation under the Health and Disability Commissioner Act 1994. It confers a number of rights on all consumers of health and disability services in New Zealand, and places corresponding obligations on the providers of those services, including hospitals.

ENDS

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