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Medication safety - prescribing errors (07HDC09719)
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In June 2007 the Health and
Disability Commissioner (HDC) received a complaint from Mr A,
regarding the services provided to his mother, Mrs A, by two
district health boards in 2003. The complaint raised serious
concerns about the collection and use of information regarding
In late July 2003, Mrs A, a 72-year-old woman, was admitted to
Hutt Hospital and diagnosed with an abscess on her spine.
Antibiotics and initial treatment were given at Hutt Hospital and
she was then transferred to a private hospital for an MRI scan.
Following the scan Mrs A was admitted to Wellington Hospital where
an operation was performed to clear the abscess.
During her initial admission at Hutt
Hospital and while at Wellington Hospital, Mrs A was given various
antibiotics. She had previously been identified as having an
allergy to cephalosporin antibiotics, but was nonetheless given
such medications at both hospitals. Mrs A developed toxic epidermal
necrolysis, a rare and serious condition characterised by the
detachment of top and lower layers of the skin, which also severely
affects the mucous membranes causing damage to airway
linings. It appears that in Mrs A's case it led to
respiratory failure, which was the cause of her death.
Care at Hutt
Mrs A had operations at Hutt Hospital in 1982 and 1995 during
which she had allergic reactions to cephradine (a cephalosporin
antibiotic) and cefamandole (another cephalosporin antibiotic).
This caused a severe rash over all her skin with purpuric or
petechial appearance and some blistering. Her GP was informed of
this allergy and it was noted on her GP record "AVOID
In January 2002 Mrs A was referred
to Hutt Valley DHB again. The referral form from her new GP, Dr B,
clearly indicated allergy to cephalosporins and possibly
On 22 July 2003 she was referred to
Hutt Hospital by the same GP for severe back pain with urinary
retention. The referral note indicated an allergy to aspirin and
Ceclor. However, the allergy section of the admission form
was not completed. Instead, someone wrote "refer to GP letter".
There are differing accounts about
the discussion of Mrs A's allergy information. Her daughter, who
was with her at the time, recalls discussions about Mrs A's allergy
to antibiotics and the reaction during previous operations. Mrs A
was a retired nurse and apparently reasonably alert when
The orthopaedic registrar who saw
Mrs A said that he read the referral from Dr B but recalled that
Mrs A only mentioned an allergy to aspirin. He recalled the
reaction as being severe and thought that she may have mentioned a
rash or swelling of the face but could not be sure. He remembered
asking about Ceclor and that Mrs A said she might have had a
symptom which the registrar considered to be more of a side effect
- along the lines of an upset stomach. The orthopaedic registrar
did agree that the previous reaction during an operation was
discussed with him but he did not recall being told about it making
Mrs A's skin peel or that an antibiotic was the cause.
Mrs A was given intravenous
ceftriaxone (a cephalosporin antibiotic) before transfer to
Care at Wellington
Mrs A was transferred from Hutt Hospital to Wellington Hospital on
23 July. The Emergency Department record noted only an allergy to
aspirin, which caused a rash. The admission notes (based on
information from Mrs A and her notes) also recorded an allergy to
aspirin, with this being flagged by a drug reaction sticker.
However, the preoperative checklist queried an antibiotic allergy
while the pre-anaesthetic assessment form noted a drug sensitivity
An operation was carried out to
drain Mrs A's abscess on 23 July, and Mrs A was transferred to ICU.
Patients are often transferred to ICU after drainage of epidural
abscesses because they may become more unwell as a result of the
dislodgement of infective material. Mrs A's postoperative recovery
was complicated by significant sepsis, pulmonary problems, acute
kidney failure and the development of a skin condition (the
Antibiotics - rash
After the operation at Wellington Hospital Mrs A was given
flucloxacillin (a penicillin antibiotic), ceftriaxone (a
cephalosporin antibiotic) and metronidazole. The flucloxacillin was
thought to have caused a fall in her blood pressure and a rash on
her torso and thighs and, on 24 July, an infectious diseases
specialist, Dr C, was consulted and recommended stopping the
current antibiotics and switching to clindamycin (a lincosamide
antibiotic) immediately. However it was two days before
flucloxacillin was stopped and, a day later, cefazolin (a
cephalosporin antibiotic) was started.
On 27 July Dr D, an infectious
diseases registrar, recommended continuing cefazolin, but the next
day Dr E, a microbiologist, recommended stopping it immediately,
which was done. Over this period Mrs A's rash continued to spread
and worsen and was described as red and sore with blistering and
peeling. She also developed mouth ulcers and a "positive Nikolsky
sign" - which means that blisters spread easily on the application
of pressure to the skin, a sign of toxic epidermal necrolysis.
Transfer to ward
Mrs A was discharged from ICU to the neuroscience ward 11
days after her operation on 3 August (during her time in ICU she
had two failed extubations). She returned to ICU on 8 August after
a cardiorespiratory arrest. The ICU records refer (sporadically) to
allergies to aspirin and flucloxacillin (both noted as causing a
rash). Mrs A was in ICU only 24 hours then was transferred back to
the neuroscience ward on 9 August. Following a respiratory arrest
on 13 August she was transferred back to ICU and subsequently
Action taken by Capital
& Coast DHB
Capital & Coast DHB agreed to carry out an independent
inquiry into Mrs A's treatment, and engaged Dr F to do so. The
inquiry commenced in November 2003 was not completed until
The executive summary in the report
concluded that "Mrs A presented with a serious illness. In the
course of her treatment she developed a number of complications. A
number of systemic weaknesses, none of them individually lethal,
combined allowed her condition to deteriorate to a critical
The report considered the matter of
Mrs A's drug reaction at Wellington Hospital and identified the
various points at which any reaction to cephalosporin antibiotics
was noted. While the full notes from Hutt Hospital were not
available, the GP referral letter (mentioning the Ceclor allergy)
and ED notes were. The report described the trail of documentation
as "disrupted and inconsistent". It stated that antibiotic choice
in situations where a patient has a life-threatening infection is
very difficult, and that the risk of reaction has to be balanced
against the need to act against infection. The report also noted
that there is a known cross-reactivity between cephalosporin and
penicillin antibiotics (such as flucloxacillin) of around 4-10
The report stated that those
treating Mrs A did not have a clear picture of her past history and
presumed reaction. The appearance and disappearance of drug
reactions from history taken from the same patient over a period of
time is not unusual. However, the evidence was there for clinicians
at both hospitals to consider, if only in the GP's referral letter.
The report stated that there is considerable potential to improve
systems for the collecting, recording and disseminating of
information about a patient's drug sensitivities. This ranges from
the use of Medic Alert bracelets to local and national electronic
alert systems in hospital patient management systems.
The report recommended that:
1. systems for documentation of allergies and adverse drug
reactions should be reviewed and strengthened. The use of
electronic alerts may be helpful;
2. documented information that comes with the patient should
be recognised, reviewed and incorporated in the hospital
The report identified the main issue
to be addressed as Mrs A's suitability for placement in a
generalised clinical setting rather than the intensive care unit,
and her subsequent movement between these two areas. A number of
conclusions and recommendations were made on this issue.
Capital & Coast DHB has taken the following actions to address
the issues around collection and use of information about
- discussion with staff about the importance of incorporating
documented information that arrives with patients in hospital
- an upgrade of the database in ICU in May 2005 to allow for
easier recognition of allergies
- a move from paper to electronic health records (both are
currently used), which has resulted in:
Admission to Discharge Planner document in the hard copy of patient
records to record allergies for admitted patients
- the recording of allergies in the alerts section of patient
medication charts (which aligns with the Safe and Quality Use of
Medicines Group's national chart - this has a standardised allergy
and drug reaction section, which will eventually make it easier to
see the information where medication is charted)
- documentation of allergies on checklist type forms, eg,
preoperative and pre-procedure checklists
- the recording of allergies through the patient information
management system (IBA) with an alert that shows when the
electronic patient record is opened
- a formal reminder to staff by the Chief Medical Officer and
Director of Nursing of the importance of ensuring that allergy
information is appropriately sought and documented.
Action taken by Hutt Valley
Hutt Valley DHB then requested Dr G (Chief Medical Advisor at
another DHB) to investigate and report on the circumstances
surrounding the care and treatment of Mrs A while at Hutt Hospital
in July 2003 and to recommend any further action Hutt Valley DHB
should take. The report was completed in August 2005 and
- The GP referral was inadequate as it noted only Ceclor as an
allergy rather than a cephalosporin allergy.
- Mrs A should have worn a Medic Alert bracelet.
- There was medical error by the orthopaedic registrar on the
basis that he did not take adequate note of the information on Mrs
A's allergy, which was reasonably available from the GP note or
"likely communication from the patient and her daughter".
- The fact that the Emergency Department nursing notes did not
indicate any allergy despite having this information reasonably
available also did not reflect a reasonable and appropriate
standard of care.
The report went on to identify
opportunities for quality improvement including:
1. using an electronic alert
2. reviewing the documentation used in the Emergency
3. documenting discussions with patient and family.
In November 2007 Hutt Valley DHB
advised that staff received ongoing education in relation to the
importance of concise professional documentation, which includes
the need to document discussions with patients or their family.
Hutt Valley DHB is moving to a full electronic medical record,
which will change the way allergy information will be stored and
accessed, and includes an alert system. The DHB anticipates
piloting the electronic alert system by December 2008.
Mrs A's estate made an ACC claim for medical misadventure
in June 2004. It was only in late 2006 that the claim process
Expert advice - Dr Everts
ACC obtained advice from Dr Richard Everts (an infectious
diseases specialist and medical microbiologist) in March 2005. He
concluded that Mrs A appeared to have suffered toxic epidermal
necrolysis with severe bronchial mucosal sloughing leading to
respiratory failure and death. This was most likely an allergic
reaction to ceftriaxone or even both ceftriaxone and
flucloxacillin. The reaction may have been further aggravated by
cefazolin. Because of Mrs A's previous severe reaction to
cefamandol, all cephalosporin and penicillin-group antibiotics
should have been avoided. Dr Everts identified the following points
of "suboptimal care and unfortunate events" as leading to the
1. Mrs A's GP, Dr B, did not accurately determine the history
of the cefamandole allergy.
2. Hutt Hospital did not have an electronic alert of the
3. Mrs A did not have a Medic Alert bracelet.
4. Mrs A and her daughter could not recall the exact name of
the medication when communicating the allergy history to staff at
5. Dr B's letter of referral did not mention cefamandole
allergy (it did mention Ceclor).
6. Neither of the two hospital staff who enquired about drug
allergies detected the cefamandol reaction documented in Mrs A's
old hospital notes despite probably being warned that it had
7. None of the Hutt Hospital staff and only two of the
Wellington Hospital staff who were supposed to enquire about drug
allergies detected the Ceclor allergy despite it being written on
Dr B's referral letter.
8. The two staff members who did detect the Ceclor allergy
did not determine or document the nature of the severity of the
9. Flucloxacillin was not stopped until two days after Dr C
recommended stopping it.
10. Cefazolin should not have been recommended or prescribed
after the severe rash developed and flucloxacillin and ceftriaxone
were suspected of being the cause.
Dr Everts initially concluded that
there had been medical error on the part of the orthopaedic
registrar at Hutt Hospital. The basis for this view was that the
registrar had misread the GP letter, not looked at old notes, and
did not document a full allergy history. Dr Everts noted that the
registrar did make some attempt to determine or consider allergies
in that he documented the allergy to aspirin. He concluded that it
was likely that the registrar was told about a serious drug
reaction and that the information could have been found in the Hutt
Hospital old notes, but he did not follow this up before
Initial ACC decision and
ACC subsequently advised Mrs A's estate that it had accepted the
claim on the basis of "medical error". The report was sent to Hutt
Valley DHB and Capital & Coast DHB. At this point the identity
of the orthopaedic registrar was not known. Hutt Valley DHB then
identified the orthopaedic registrar and he provided a report on
the matter and asked that Dr Everts review his report in light of
this new information.
The orthopaedic registrar
1. The old notes were not available to him during Mrs A's
admission and there was no computerised database.
2. He took a full history including medications and allergies
and, based on the details given by Mrs A and her daughter, noted
only an allergy to aspirin.
3. The orthopaedic registrar agreed that the problem with Mrs
A's operation (when there was a reaction to cephalosporin) was
mentioned but he was not sure that the head-to-toe peeling of skin
was mentioned. He does not recall Mrs A or her daughter mentioning
that an antibiotic caused it.
Revised ACC decision
On the basis of this further information, Dr Everts provided a
supplementary report in August 2005. He changed his initial view
and advised that he did not think there was medical error on the
part of the orthopaedic registrar. A legal review of the matter was
undertaken and it was recommended that the finding of "medical
error" be set aside and that the claim be accepted as an
"organisational error" on the part of both DHBs. Both DHBs objected
to this recommendation, and the claim was accepted by ACC as
"medical mishap" in November 2006.
1. Mrs A's case highlights the importance of accurate and
consistent collection of information regarding medication
allergies/sensitivities. Collecting such information is of little
use if it is not readily accessible to practitioners treating the
patient or if such practitioners do not refer to it.
2. All relevant information should be set out in the
admission form - it is inadequate simply to refer to another
3. Taking an accurate history of a patient's condition,
including allergies/sensitivities, is a key competency for all
doctors and nurses. Referring to old clinical records is essential,
particularly when faced with information that is unclear or where
its accuracy is not certain. It was done poorly in this case.
The Centre for Adverse Reactions to Medicines (CARM) in Dunedin
provides a service to verify allergies, and should have been
contacted after the patient's first reaction.
It is concerning that, despite the apparent severity of the
reaction to the medications given, the practitioners treating Mrs A
did not identify her allergy. The allergy had been identified at
least twice in the preoperative and pre-anaesthetic checks. Staff
at Wellington Hospital did not identify this information, or seek
information from Hutt Hospital or Dr B (Mrs A's GP). I note Dr
Everts' advice to ACC that "penicillin and cephalosporin-group
antibiotics are among the most common causes of Toxic Epidermal
4. Moving to an electronic record and alarm system may
address some of the concerns raised by Mrs A's case. It will not
necessarily address the issue for patients being transferred
between DHBs - medication reconciliation when transferring patients
between hospitals should include an allergy identification system.
Nor will such a system remove the need to accurately document
allergies/sensitivities in the first instance.
For several reasons I have decided
not to undertake a formal investigation of this matter. The events
occurred nearly five years ago, and Mrs A's family has already gone
through a lengthy investigation by Capital & Coast DHB, a
belated inquiry by Hutt Valley DHB, and a protracted ACC
investigation process. All parties recognise the need for
However, it is important that the
educative value of these events is recognised and used to assist in
improving medication safety. I will bring this case to the
attention of the Safe and Quality Use of Medicines Group and the
Quality Improvement Committee. Copies of this casenote will be sent
to all DHBs.