Last week we saw a number of reports on the Inquest into the death of Paul Lau.
Here is one such:
Computer prescribing error turns 'uneventful' procedure fatal
An anaesthetist accidentally used the wrong patient file
4th April 2018
A father of two died in hospital following a routine knee reconstruction because his anaesthetist accidentally entered fentanyl into the wrong computer file, the NSW Coroner’s Court has found.
Paul Lau, 54, died from multiple drug toxicity after being mistakenly prescribed fentanyl intended for another more complex surgical patient at Sydney’s Macquarie University Hospital in June 2015.
The most likely explanation for the prescribing error was that the anaesthetist, Dr Orison Kim, left Mr Lau’s file open on a computer and then returned to theatre, the inquest heard.
He’d been using the hospital’s new electronic prescribing system, TrakCare, and came back to the computer at a later time to enter medication for another patient. However, he accidentally prescribed a fentanyl patch and patient-controlled analgesia for Mr Lau, whose file was still open.
Mr Lau had already been prescribed oxycodone tablets and paracetamol for an “uneventful” anterior cruciate ligament reconstruction.
Dr Kim overrode 22 alerts in three batches while entering the medications, selecting “consultant’s decisions” and entering his password each time.
“It is clear that Dr Kim failed to exercise proper care, diligence and caution whilst prescribing medication erroneously in Paul’s TrakCare record,” acting State Coroner Magistrate Teresa O’Sullivan said in her findings.
Lots more here:
https://www.australiandoctor.com.au/news/computer-prescribing-error-turns-uneventful-procedure-fatal
Following up here are the full recommendations to the Hospital:
To the Macquarie University Hospital
1. That a working party be established to consider lessons learned and possible reforms which could be implemented at Macquarie University Hospital (“the Hospital”) as a result of the death of Paul Lau on 19 June 2015:
a. That the working party comprise a representative from at least Information Technology (“IT”), the Anaesthetics & Perioperative Services Department (“Anaesthetics Department”), the Nursing directorate, the Macquarie University Pharmacy (“the Pharmacy”) and the Patient Safety and Quality Manager.
2. That the working party consider, or in the alternative, the Hospital considers, the most effective way to implement the following suggested reforms:
Presentation of Paul Lau’s Case
a. A staff seminar or seminars be conducted with the participation of staff from at least the Anaesthetics Department, nursing staff and the Pharmacy about the missed opportunities to detect the prescribing error in Paul Lau’s case and the lessons learned from his death;
That the nursing staff involved in Paul’s care be consulted about how that seminar be presented and have the opportunity to address the seminar if they wish; and
c. That the seminar address, at a minimum, communication, handover, opioid policy, observation of patients on high-risk medication, Schedule 8 checks and responding to patient deterioration.
TrakCare Changes
d. Give ongoing consideration to a method of verifying patient identity before medical practitioners submit medication orders on TrakCare, including specific consideration of:
i. Urgent short term methods of ensuring patient identity verification if software changes are likely to be prolonged in implementation; and
ii. The manual entry of the patient’s name prior to submitting a medication order;
e. A field/box labelled “current medications” or “medications history” (as determined appropriate) be included in the pre-anaesthetic assessment (see Tab 36C, Annexure C of Exhibit 1);
f. A field labelled “post-operative pain plan” (or other description as determined appropriate) be added to the Recovery Progress Notes template (see Exhibit 5);
g. That investigation be undertaken into the feasibility and efficacy of an alert when medications are added to a patient’s chart after the patient file is allocated to PACU/Recovery;
h. That representatives of at least IT and the Anaesthetics Department consider the most effective way of ensuring that TrakCare alerts enhance patient safety without unduly distracting or diverting anaesthetists; including
i. How to safely reduce the number of alerts;
ii. Removing the default ‘batch’ override system;
iii. Creating a hierarchy of alerts;
Creating a distinct alert for identical duplicate “one touch” prescribing;
v. The effective use, if any, of font, format, sound, colour and placement for alerts; and
vi. Known literature and clinical guidelines on safe e-prescribing.
TrakCare Proficiency
i. That medical practitioner accreditation include a TrakCare assessment process whereby it is mandatory for a person separate from the user to confirm that the user is proficient to safely use the system;
j. That consideration be given to the most appropriate person to conduct the assessment and if the assessment would be more effective in person or on-line; and
k. That TrakCare proficiency for anaesthetists be assessed by the use of simulations or scenarios designed in consultation with the Anaesthetics Department.
Handover Practices
l. That a staff seminar or seminars be held involving staff from nursing and the Anaesthetics Department about handover practices which would include simulations of handovers by staff, the provision of feedback and discussion of mechanisms to enhance the communication between nursing staff and anaesthetics staff;
m. That an audit or audits be conducted in relation to safe handover practices at the Hospital with particular priority given to practices at PACU/Recovery;
n. That there be a minimum number of audits conducted annually at appropriate intervals; and
o. That the results of those audits be published on the Hospital intranet and be held by the Nursing Directorate.
Perioperative Management
p. That, at least, representatives of the Anaesthetics Department and the nursing staff consider mechanisms to provide safe and effective perioperative management for patients, including:
i. Monitoring of patients taking high risk medications;
ii. Postoperative review of patients by anaesthetists in PACU/Recovery and on the ward;
iii. The introduction of a pain service; and
iv. Relevant existing clinical guidelines including Australian and New Zealand College of Anaesthetists guidelines, Clinical Excellence Commission guidelines and any known proposed upcoming reform.
----- End Extract
Here is the link to the full report:
I have to say this report seems very much to be a consensus co-operative finding where some very sensible approaches are recommended and are apparently being implemented.
To my mind it is a combination of inadequate user training and poor system design and screen layout that are at fault and that serious efforts are being made on both these fronts.
All that remains is to educate the whole of the profession of the risks and work to optimize design safety with the software.
David.
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