Thursday, May 17, 2018

This Made Me Wonder Just What Was Happening With The “Bonfire Of The Faxes”?

This appeared last week:

He died alone after his medical test results were faxed to wrong number

By Melissa Cunningham
10 May 2018 — 6:08pm
Mettaloka Halwala was alone in a hotel room near Shepparton when he was found dead from complications that arose from his chemotherapy treatment of Hodgkin’s lymphoma.
Hotel staff opened the door of his room on the morning of November 17, 2015 to find the 58-year-old father of two deceased in his bed, fully clothed in jeans and a shirt, a lit torch beside him.
Now, a Victorian coroner has found Mr Halwala's lonely death could have been prevented had he not been let down by a series of systematic failures by the medical profession.
Four days before Mr Halwala's death, a scan conducted at the Austin Hospital showed signs of potentially fatal lung toxicity linked to his cancer treatment.
But a fax with the results of his scan was sent to the wrong number, Coroner Rosemary Carlin found.
This, combined with other "shortfalls in his medical management", meant neither Mr Halwala nor his haematologist Dr Robin Filshie at St Vincent's Hospital Melbourne was made aware of the results before a further fatal dose of same drug associated with the lung toxicity was administered.
While no one acknowledged responsibility for the communication failure, Ms Carlin found there had been "inadequate medical management" at the hands of both Dr Filshie and the physician responsible for sending the report, Associate Professor Sze Ting Lee.
"I cannot be certain that Mr Halwala would have survived even with optimal treatment but he may have," she wrote.
"The shortfalls in his medical management deprived him not only of his chance of survival but also of the opportunity to have a more comfortable death surrounded by loved ones."
In the months leading up to his death, Mr Halwala, affectionaly known as Mal, was living in a hotel in Tatura, a small town in the Goulburn Valley, due to his work as a civil engineer, while his family lived back in New Zealand.
Lots more here:
Now this is a sad story but really the specialist who ordered the scan and did not follow up is the one who should receive the most opprobrium.
That said the fax replacement program seems to have ground to a halt and I understand there are three contending views of the future slowing things down. Roughly there are those who want to finalise HL7 2.4, the pragmatists and the FHIR enthusiasts who want to move more quickly to the probable future.
Maybe we could have some leadership from the ADHA and move on, or is that too much to ask. It’s been almost two years now! That said my little Brother Multifunction (fax) has been a godsend in getting all my results during my recent travails! The fax sure is not dead yet…..
David.

3 comments:

Anonymous said...

The question is regardless of the technology would is the sender informed if the receiver receives the message and has the receiver opened the message? This would appear a process related incident not whether it is a protocol issue. In fact perhaps in the age of to many electronic messages this might happen more with other forms of electronic communication

Andrew McIntyre said...

It is possible to send any number of ACKs to a message and with some systems we have a "View ACK" to tell you the person has seen the result, which can be useful.

The lack of electronic ordering makes it nearly impossible to reliably know if what you have ordered has returned. With serious, significant findings human communication of the result is still vital. If you don't have a "View ACK" then you need a verbal one. Messaging mirrors the way the world works and if you tell someone something important you look for a response that indicates they have heard you.

Anonymous said...

Heard and hopefully understood? Perhaps that might be a risk with MyHR you will hear recording (reading an early transcript in the form of a document) but that may not be truely understandings what was meant in the context when it was created. The MyHR may just be creating a barrier between human communications? Time will tell I guess