Six hours after knee reconstruction surgery, a healthy 54-year-old NSW man died after he was given medication meant for another patient, an inquest has heard, with accidental misuse of the hospital’s recently implemented electronic system to blame.
Paul Lau had entered Macquarie University Hospital for the routine operation on his left knee, but died from "multiple drug toxicity" in June 2015.
At the inquest in the NSW Coroners Court into the medication mistake, counsel assisting the inquest Kirsten Edwards said Lau died after anaesthetist Dr Orison Kim entered the details for a much stronger pain medication into the month-old InterSystems TrakCare electronic medical record system.
"There was a serious prescribing error during the surgery and then a failure to detect that error," Edwards said.
The inquest heard that despite indications the medication administered was not appropriate, the error was not picked up by nurses or Dr Kim during post-operative care for the father of two.
"Your honour might find there were more than 15 missed opportunities to detect that prescribing error and save Paul's life," Edwards told the inquest.
"These sorts of deaths just shouldn't happen in a modern, advanced medical facility."
According to Dr Kim, he had not been provided with any formal training in the use of the TrakCare system.
Lau's son, Johnathan, speaking outside the court said he hopes such an error doesn’t happen again, calling for training to be put in place and changes to hospital procedures.
"Systems need to be in place, guidelines need to be standardised."
Following Lau's death, Macquarie University Hospital implemented changes to its EMR procedures.
The inquest continues.