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Health and Disability Commissioner report on high paracetamol dose for frail patient

Waikato DHB takes responsibility and unreservedly apologises for the breach of the Health and Disability Code and inadequacies in the care of a 77-year-old woman, as outlined in the Health and Disability Commission report released today. She died in Waikato Hospital on 3 December 2012.

Executive director of Waikato Hospital Services Brett Paradine said that since the death of the woman, significant changes have taken place. “However we never lose sight of the fact that improvements to our systems and processes have come about through a most distressing experience for her family. In the end, all our medical knowledge and processes have the aim of providing the best care we can, and in this instance it didn’t happen.

“I have personally written a letter of apology to the family and I am committed to making sure the lessons we have learned are embedded in our organisation.

“We are putting audits and checks in place that will make sure we keep improving in those areas.”

The case involved a frail 77-year-old woman, who required urgent bowel cancer surgery and had post-operative issues, and who was placed on paracetamol for pain management, then becoming ill with paracetamol toxicity and suffering acute liver failure. The Health and Disability Commission report found that Waikato DHB had breached the code in that it did not recognise her accumulative paracetamol toxicity and did not take into account her low body weight nor her abnormal liver function when prescribing paracetamol.

Among the actions already taken by Waikato DHB as a result are:

  • A full discussion of the case and learnings by Waikato DHB’s Mortality and Morbidity Review Committee.
  • Increased surgical staff awareness of the need for paracetamol adjustment in patients with low body weight and for caution in its use in patients with liver failure, and that prescribers and clinical teams cannot rely on serum paracetamol levels in the setting of chronic toxicity.
  • The auditing of medication charts to check whether charts are properly updated where medications have been discontinued. This audit (in late August/early September 2015) identified some inconsistencies and scope for improvement. The audit will be repeated in October/November 2015.
  • Developing ways nursing staff can share learnings from events such as this as part of continuously improving their patient care.
  • Continue to promote the use of the SBARR clinical communication tool among staff especially at handover of patients. In the case of this woman, the communication between nursing staff and medical staff did not take place to the extent it could have to raise the possibility of withholding paracetamol.

Regarding the last point, Waikato DHB endorses and recommits to the statement made by the Health and Disability Commissioner Anthony Hill in his report:

“It is essential that teams consistently communicate well with one another to ensure that a safe and seamless service is provided to the patient. It is also essential that clear communication is accompanied by accurate documentation. Clear communication and accurate documentation form two of the layers of protection that operate to deliver seamless care.”

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