KEY POINTS:
An Auckland man died after a hospital mixed up a fax from his GP giving details of his medication with those of another patient, resulting in his receiving a fatal combination of the wrong drugs.
Auckland City Hospital has apologised for the blunder after the Health and Disability
Commissioner found it had committed a chain of errors causing Mervin McAlpine's death.
Mr McAlpine, a diabetic, died at Auckland City Hospital after a letter from his GP was mistakenly attached to another patient's medication records and lab results, faxed to the hospital at the same time.
The 82-year-old - who had lost both legs and was sent to hospital because he was not coping at home - was then prescribed two drugs he was not supposed to have.
The Auckland Coroner found that Mr McAlpine died of complications from the administration, in error, of metformin and glipizide.
In a report made public today, Health and Disability Commissioner Ron Paterson says the hospital committed a chain of errors in Mr McAlpine's care in August 2004:
* Staff did not check where the records of the other patient had gone after finding them missing from his file.
* The house surgeon did not check Mr McAlpine's current medications, which he brought with him as requested, but was never asked to produce.
* The nursing assessment left the medications part of the form incomplete.
Mr Paterson says Mr McAlpine's death was a result of "systemic weaknesses" in the hospital's referral and prescribing processes.
"Hospital staff need to ensure that a complete and accurate list of a patient's current medication is compiled, checked and reconciled to ensure that the patient is prescribed the appropriate medication at the appropriate dose, in secondary care.
"The series of events that led to [Mr McAlpine's] death could occur at other hospitals. There is therefore a need to highlight these systemic weaknesses to other district health boards."
A friend of Mr McAlpine, Peter Larkin, lodged the complaint after the hospital acknowledged prescribing the wrong drugs.
"I was quite disgusted at how easy it was for him to have been given wrong medicine and the fatal consequences of it.
"At the end of the day, whatever we are doing now is not going to affect Mervin.
"He's dead, he's died from it, but this needs to be brought to the public's attention - how easy it is to be given the wrong medicine.
" ... Nobody bothered to read anything, [they] paperclipped it together and just put it in."
Mr Larkin had known Mr McAlpine since childhood, and helped look after him in his later years. The former council worker lived alone in a pensioner village in Mt Eden, but had family in Hawkes Bay.
Mr Larkin hopes the report will prevent something like this happening again.
"What I'd really like to see is the report making changes."
The hospital acknowledged the commissioner's findings. The chief medical officer, David Sage, said: "The patient's recovery was so compromised by the administration of incorrect medication for diabetes that we hastened his death."
Dr Sage said the hospital had since taken steps to correct the situation, including altering GPs' software to add patient ID and pagination to faxes. The hospital had found that 86 per cent of faxes from GPs were now marked with patient data, compared with 23 per cent in 2004.
The number of administration staff processing the paperwork has also been increased.
Dr Sage said he supported the commissioner's call for a national approach in developing a system to reconcile medications - a move also supported by the Royal College of GPs.
At present there is no centralised system for doctors at different levels of care to gain access to patient records.
The problem is compounded by the lack of a standardised software system among GPs and hospitals, which can hinder sharing of patient information.
A Ministry of Health committee is looking at improving the communication between patients moving from GP care to the hospital and back again.
Communication errors have been linked to the deaths of at least three other patients in the past three years.
Inadequate communication, documentation and monitoring contributed to the death of a 50-year-old man who died 40 hours after admission to Wellington Hospital with pneumonia.
A heart patient with chest pain, breathlessness and lethargy was sent home from Wanganui Hospital three times in 11 days after she was referred by her doctor.
Each time, the GP was not told the patient had been discharged. She died at home in January 2004 the day after the final discharge. Hospital doctors said they did not fully realise her doctor's level of concern.
Inadequate medical record-keeping was blamed when an asthma sufferer with a migraine was prescribed medication to which she was allergic by a doctor at an unnamed North Island medical centre.
The patient usually saw a different doctor at the centre but her file had no record of her allergy. The woman stopped breathing, suffered severe brain damage and later died.
