Lakes DHB apologises for death of patient
6/08/2019 8:53:50 a.m.

5 August 2019

Lakes District Health Board is extremely sorry about the unfortunate combination of events that led to the untimely death of one of our patients.

Quality, Risk and Clinical Governance Director Dr Sharon Kletchko says Lakes DHB continues to express its heartfelt apology and condolences to the family of this patient for the unexpected loss of their loved one. Lakes DHB is passionate about providing a high level of care for our patients and takes any shortcomings very seriously.

Health and Disability Commissioner Anthony Hill has 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.

Lakes DHB is resolved to never see another serious adverse event to do with the prescribing of anticoagulants and has improved its processes as a result of this event. We are also consequently influencing a better understanding of this prescribing error nationally.

Lakes DHB assisted with the content of the Health Quality and Safety Commission’s (HQSC) Open Book on this subject in 2017, which highlighted that this type of prescribing error is not limited to Lakes DHB. (An Open Book is a report to alert providers to key findings of adverse event reviews emphasising what needs to be done to stop the event happening again).

Lakes DHB reviews all serious adverse events using a root cause analysis (RCA) methodology, with a senior clinical team looking at exactly what happened and what could be done to prevent any errors and improve any issues. The Health and Disability Commission expert opinion has agreed with the recommendations made following the root cause analysis (RCA) of this event.

Dr Sharon Kletchko says there have been a number of changes made to ensure our clinical and managerial processes support patient safety, particularly related to the specific medications that impacted so seriously on this patient. Lakes DHB has:

• Established a new Medicines Safety Committee that has implemented a number of interventions to improve the safety of anticoagulant prescribing and administration for patients throughout our hospitals. Further changes are currently being tested.
• Shared this patient’s story, with the family’s consent, regionally and nationally, and a poster was presented at the Institute for Healthcare Improvement conference in Melbourne (2018) to raise awareness of this type of prescribing error.
• Requested specialist haematologist advice to inform an updated policy and a procedure for the monitoring of patients on Novel oral anticoagulation therapies.
• Developed and is now testing new alert stickers related to anticoagulant prescribing and administration, as well as trialling a medication sheet used only for anticoagulant prescribing and administration.
• Removed one of the medicines involved from ward imprest stock at Rotorua Hospital; meaning all prescriptions should be seen and reviewed by a pharmacist or Duty Nurse Manager.
• Reviewed and updated Lakes DHB’s Open Disclosure Policy and Procedure (which looks at how Lakes DHB communicates a patient’s condition to the family) and undertaken training with the Cognitive Institute. This includes procedural steps to follow when open disclosure is necessary.
• Proactively worked with the HQSC on the improved use of the Early Warning System (EWS) a method to identify a deteriorating patient who needs immediate clinical attention. This included nursing orientation and training on the use of the EWS tool.
• Actively participated in and contributing to the Midland Regional Deteriorating Patient programme.
• Reviewed Lakes DHB Emergency Department stroke protocols and clinical documentation guidelines.
• Recommended an update in the Ko Awatea e-learning tool that provides doctors with a good understanding of the appropriate use of the National Medication Chart.
• Shared the systems and contributory factors issues discovered as part of this serious adverse event review and raised concerns regarding the misunderstanding of the term “bridging” with the Health Quality and Safety Commission’s Medication Safety Expert Advisory Committee (MSEAG).
• Liaised with Medsafe and the medicine’s manufacturer to ensure the Safety Data Sheet for the medicine was amended to remove ambiguity.
• Influenced the HQSC MSEAG literature review on the prescribing and administering of anticoagulants and review of the Hospital Inpatient National Medication Chart.
• Developed an audit plan and is in the process of testing an audit tool that affirms the effectiveness of Lakes District Health Board’s documentation and responsibility in relation to Resident Medical Officers (RMOs) weekend documentation, to ascertain the compliance with Medical Council of New Zealand standards for maintaining patient records as required by the HDC. Lakes DHB has been given six months to provide evidence of improvement. 

For more information contact: Sue Wilkie Communications Officer or Shan Tapsell Assistant Communications Officer Phone (07) 349 7944 or mobile 027 242 3652