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Inappropriate co-administration of anticoagulants

Inappropriate co-administration of anticoagulants - identification of knowledge deficit

Health and Disability Commissioner Anthony Hill today released a report finding Lakes District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care provided to a woman in relation to a medication error, subsequent care, and disclosure.

The Commissioner’s investigation identified a number of issues regarding education, guidelines, and policy and implementation failures at the DHB.

The woman was admitted to hospital under the care of a doctor. During the course of her stay the woman was treated with both Clexane and dabigatran for a pulmonary embolism (PE). Either medicine can be used to treat PE, but they should not be administered together. The woman later died.

While the Commissioner was critical that the doctor prescribed the drugs together when it was contraindicated, his investigation identified a more widespread lack of clarity around their use at the time. Within the hospital there was also a lack of knowledge amongst some clinicians around the correct process for switching to dabigatran. The Commissioner considered that the DHB’s anticoagulation guidelines were inadequate as they lacked clarity, were contradictory, and needed to be updated. He also said that the hospital pharmacy should have been clearer in enforcing that the two drugs should not be administered concurrently.

"The pharmacy review is an important safety-net to check, and sometimes challenge, prescribing," Anthony Hill said.

In addition to the medication error there were other issues with the use of existing DHB tools and policies. The woman deteriorated during her stay at the hospital and, had the DHB’s communication tool been used, it is likely that the woman’s care would have been escalated sooner.

When the medication error was discovered, the doctor disclosed this to the woman’s family and apologised. The Commissioner considered that the way in which the error was disclosed was not ideal, and he was critical of both the content of the DHB’s open disclosure policy, and communication of the policy to staff.

The Commissioner made a number of recommendations to Lakes DHB regarding improvements to its policies, guidelines, and documentation. He also asked the DHB to apologise to the woman’s family.

The full report for case 17HDC00191 is available on the HDC website.


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