An anaesthetist’s accidental misuse of a month-old electronic medical record at Macquarie University Hospital in 2015 was responsible for the death of a 54-year-old man following routine knee surgery, the NSW State Coroner has found.
Six hours after an uneventful knee reconstruction, Paul Lau died after being administered medication meant for another patient, Acting State Coroner Magistrate Teresa O’Sullivan said in her findings.
The February inquest heard from eight witnesses on the events leading up to Lau’s death in the early hours of June 19, despite attempts to resuscitate him.
According to the Coroner, the hospital’s recently implemented InterSystems TrakCare
electronic system, which had gone live on May 2, had been used by anaesthetist Dr Orison Kim to prescribe Lau’s drugs.
Following the surgery, the Kim was in theatre with another patient (Patient GS) when he re-entered Lau’s electronic chart to prescribe fluids necessary to “keep the line open” for intravenous antibiotics that had earlier been forgotten. But Kim failed to close Lau’s record. Minutes later, the anaesthetist prescribed doses of the opioid fentanyl meant for Patient GS in Lau’s open file.
According to the coroner’s report, while Kim was inadvertently prescribing the incorrect medications on Lau’s chart, 22 alerts were triggered by the TrakCare system. They were manually overridden by the anaesthetist.
O’Sullivan found that a series of opportunities to save Lau’s life – including through intervention by pharmacy or nursing staff – had been missed, but ultimately it was Kim who had failed to exercise proper care, diligence and caution in the use of Lau’s TrakCare record.
“Dr Kim accepted that a patient’s name is displayed on screen in TrakCare at all times and that he overrode 22 alerts presented in three batches whilst prescribing, selecting ‘consultant’s decision’ and entering his password each time. Dr Kim accepted that he bears primary responsibility for the error.”
The coroner found that while the EMR made the medication mistake easier, it was not to blame.
“Whilst TrakCare did not cause Paul’s death, the initial prescription error was made easier due to a function of TrakCare of great utility – the ability to open and close different patient records from a single terminal. Prior to the introduction of electronic medical records, it was much more difficult to chart medication on the wrong patient file.”
But she made a series of recommendations for changes to TrakCare, including improved processes for verifying patient identity.
The autopsy found that Lau died of aspiration pneumonia resulting from mixed drug toxicity.
He is survived by sons Johnathon and Curtis.