The Assistant Commissioner for Health and Disability, Dr Vanessa Caldwell, today released a report finding that the Hutt Valley District Health Board (HVDHB) breached the Code of Health and Consumer Rights disability (the code) for its inadequate processes for handling allergy information and communicating with a general practice.
In this case, a man was being treated for an injury while on vacation and there was no alert on the national medical alert system of a potential flucloxacillin allergy that had been evident during a previous visit to his DHB home just three weeks ago. Subsequently, he was treated with intravenous flucloxacillin and sadly died of anaphylactic shock shortly thereafter.
Deputy Commissioner Dr Vanessa Caldwell felt that her home DHB, the HVDHB, had an inadequate system to ensure allergies were recorded and reported in the National Medical Alert System (MWS), and for its inadequate communication with the usual general medicine of man.
The National MWS is an alert service linked to National Patient Health Index numbers, and is designed to alert health and disability support services to any known risk factors that may be important when clinical decision-making regarding individual patient care.
“The purpose of the MWS is to alert health and disability support services to any known risk factors, such as allergies, which may be important when making clinical decisions about individual patient care. system has been linked to the National Health Index patient numbers so that these alerts can be accessed and viewed across New Zealand.
“Maintaining the content of the MWS is primarily the responsibility of healthcare providers. However, there is currently an inconsistency in how warnings are handled, with each DHB having adopted their own processes and delegations as to what notifications can be added. and by whom.
“This case is an example of the weaknesses that exist in the current system. Undoubtedly problems with the national system contributed to these events, I nevertheless consider it vital for individual medical centers and DHBs to have their own adequate systems and processes in place for drug and medication allergies, to ensure that staff are adequately supported in their decision-making and reporting requirements,” said Dr Caldwell .
In his report, Dr Caldwell reminded the HVDHB of the importance of ensuring that all communication with patients, particularly regarding advice as vital as allergy information, is complete and documented, and that patients have a good understanding of the implications.
“The Code gives people the right to effective communication and the right to be fully informed. Healthcare professionals are expected to communicate clearly with their patients in a way that allows the patient to fully understand the information provided,” said Dr. Caldwell.
Dr. Caldwell recommended that the medical center undertake an audit to ensure that important information contained in the patient discharge summaries received is implemented, and that the HVDHB undertake intermittent audits to determine whether their policies regarding new allergies requiring action are adequate and respected.
She also recommended that the HVDHB develop an end-to-end process for emergency departments and general hospitals when a patient presents or experiences a new actual or suspected drug allergy, and recommends designing and implementing a new discharge form and create a set of educational materials for use throughout department teaching sessions and staff inductions to address expected general standards of practice with respect to drug allergy reporting and follow-up actions .
The full report for Case 19HDC02039 is now available on the HDC website.
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