Hutt Valley DHB has been found in breach of the the Code of Health and Disability Services Consumers’ Rights after a patient was given medication he was allergic to due to incorrect record keeping, resulting in his death.
A report released by Deputy Health and Disability Commissioner Dr Vanessa Caldwell on Monday states the incident occurred when a man was in hospital and being treated for an injury while on holiday. There was no alert on the hospitals National Medical Warning system of a potential allergy to flucloxacillin.
"The man was treated with flucloxacillin intravenously and sadly died of anaphylactic shock shortly afterwards," the report states.
He previously visited Hutt Valley DHB (HVDHB) three weeks prior where his allergy would have been evident.
Caldwell said: “His home DHB, HVDHB, had an inadequate system for ensuring that allergies were recorded and flagged in the National Medical Warning System (MWS), and for its inadequate communication with the man’s usual general practice.”
"The purpose of the MWS is to warn health and disability support services of any known risk factors such as allergies that may be important when making clinical decisions about individual patient care. The system has been linked to patient National Health Index numbers so that these alerts can be accessed and viewed throughout New Zealand.”
"The responsibility for maintaining the content of the MWS rests primarily with healthcare providers. However, currently there is inconsistency in the way in which warnings are managed, with each DHB having adopted its own processes and delegations as to what notifications can be added and by whom.”
Calwell outlined how the case is "an example of the weaknesses that exist within the current system".
"Without doubt issues with the national system contributed to these events, I nonetheless consider it vital for individual medical centres and DHBs to have their own adequate systems and processes in place for drug and medication allergies, to ensure that staff are supported adequately in their decision-making and reporting requirements."
Caldwell’s report gave a number of recommendations on how HVDHB could fix their processes going forward.
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