Over-reliance on the electronic medical record at Perth’s Fiona Stanley Hospital has been blamed in the death of a 41-year-old man from a serious adverse drug reaction, the West Australian Coroner has found.
Jared Olsen died on 5 March 2015, weeks after being prescribed an immunosuppressant medication, 6-Mercaptopurine (6-MP), to treat his Crohn’s colitis.
Coroner Ros Fogliani found that blood tests ordered at FSH on 8 February had determined Olsen was unable to metabolise 6-MP due to two non-functioning copies of the TPMT gene. PathWest had uploaded the “critical” results into the FSH iCM electronic record system on 19 February 2015, with a red flag indicating an abnormal result.
But by then Olsen had been discharged and due to “systemic failures”, clinicians were not alerted to the results.
“It is profoundly disturbing for the deceased’s father to have to bear the knowledge that the information that could likely have saved his son’s life was available at FSH, on its computer system, but with no adequate system or process for conveying those abnormal test results to the attention of his treating clinicians,” Fogliani found.
On 1 March Olsen collapsed and was admitted to FSH’s ICU. He died from septic shock and marrow aplasia, attributed to 6-MP toxicity, days later.
The coroner said communication between clinicians and rotating shifts contributed to the “preventable” tragedy.
“The inquest highlighted the risks for patients when too much reliance is placed on electronic communications in an environment where clinicians routinely work on rotation and in team environments,” the coroner found.
“For the deceased this risk crystallised, with tragic consequences, when a series of events led to significantly abnormal test results being received electronically at FSH, with no clinician becoming aware of them.”
According to the coroner, the deceased’s care at FSH was deficient and fell below the standards that should ordinarily be expected of a public hospital.
“The evidence at the inquest begged the question of how such a critical test can be ordered and results received at a hospital without any treating clinician becoming aware.”
However, FSH claimed the iCM — a statewide system — lacked an alert when a patient had been discharged.
“It is submitted to me that modification, upgrade or replacement of iCM is a matter for the WA health system broadly,” the coroner said.
However, Fogliani recommended FSH introduce its own robust systems to track test results in iCM, including for discharged patients, and ensure they reach the clinicians who ordered tests and the consultants in charge of treatment. She said the systems need to highlight urgent and abnormal test results.
The coroner also recommended the WA Department of Health consider whether similar measures should be adopted across the state’s public health system.
In a statement, FSH said following Olsen’s death it had implemented significant changes to clinical processes and is reviewing the coroner’s recommendations.
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