Patient with severe allergy to penicillin given it in hospital, dies from anaphlaxis

Whangārei Hospital in Northland where an elderly woman died from anaphylaxis after she was given an antibiotic she was allergic to. Photo / Tania Whyte

A hospital patient with a severe allergy to penicillin went into anaphylactic shock and died after she was prescribed antibiotics containing the medicine, despite it being noted on her chart.

Now the Health and Disability Commissioner (HDC) has found a senior doctor, a junior doctor, and a nurse at Whangārei Hospital breached the patient’s rights by prescribing and administering Augmentin without checking for an allergy.

Te Whatu Ora Te Tai Tokerau Northland District, previously Northland District Health Board, was also found in breach.

In total, there were five checks missed that busy weekend day in 2020 including by the two doctors, a pharmacist, and the nurse, who each could have prevented the tragedy.

The patient, a woman in her 80s, had been recovering from gynaecological surgery only two weeks earlier when she was readmitted to hospital with lower abdominal pain and fever.

An emergency department junior doctor noted an allergy to penicillin in a computer ED admission note, but she only listed it on the front page of the woman’s physical chart and did not fill out the rest of the fields other than to refer back to the front page.

A yellow sticker that would have indicated an allergy was not used in the clinical file and nobody remembered whether the patient, known as Mrs A, was wearing a red hospital band which also would have indicated allergy.

However, Mrs A was wearing an allergy alert necklace that said: “Penicillin anaphylactic shock”, which she had worn since her first reaction to penicillin in the early 2000s.

Mrs A was prescribed intravenous antibiotics cefuroxime and ertapenem, following advice from the microbiology service and she was transferred to a surgical ward.

By day five Mrs A was not improving and it was suspected she was suffering from a urine and kidney infection unrelated to her surgery so she was transferred to a general medicine ward.

There a registrar saw the allergy warning and made a note to continue the cefuroximne “for now”.

A nurse was not told about the allergy in a handover but she continued giving the same antibiotic.

The next day a senior doctor, Dr C, reviewed Mrs A on the ward round and checked her lab and microbiology report at a computer away from the bedside, noting E.coli was present and that Augmentin would better treat it.

He considered a penicillin allergy but was reassured because Mrs A was already receiving cefuroxime, and traditional teaching was that if someone had an allergy to penicillin, cefuroxime would not be prescribed.

He made the decision to switch to Augmentin without telling the patient, and had a house officer, Dr D, prescribe it for her.

Health and Disability Commissioner Morag McDowell recommended Te Whatu Ora Northland consider how it could improve recognition of documented drug allergies. Photo / Dean Purcell

The junior doctor told the Health and Disability Commissioner Morag McDowell he wrote the prescription at a time when he had worked 59 and a half hours across the previous seven days and did not see the allergy warning.

A registered nurse, RN E, began her shift that afternoon and was advised Mrs A had been charted a new antibiotic which was to begin that evening.

She told the HDC there wasn’t time for nurses to read entire medical records because of heavy workloads. Instead, she checked the past 24 hours of progress notes.

Though she checked the front cover of the medication chart she did not see the allergy warning and asked Mrs A if she had any known medication allergies to which Mrs A said she was not aware of any.

This was in contrast to earlier instructions from Mrs A to other medical staff that she could not have penicillin but the nurse said Mrs A was tired and sleepy at the time and may not have understood the question.

Halfway through administration of the Augmentin Mrs A began to feel nauseous and had shortness of breath. RN E suspected anaphylaxis and rang the emergency call bell.

Despite two hours of CPR Mrs A died at 9.10pm that day.

In response to the HDC investigation Dr C said while he accepted overall responsibility there were additional checks in the process that did not identify the allergy.

These included by the junior doctor who was physically prescribing the medication, the pharmacist’s check of the prescription sheet, the nurse’s check of the prescription to identify allergies prior to administration, and the nurse’s check with the patient.

McDowell found the two doctors and nurse breached Right 4(1) of the Code of Health and Disability Services Consumers Rights, to services of reasonable care and skill.

She also found Te Whatu Ora Te Tai Tokerau breached Right 4(1) of the Code for a lack of policies and failing to adhere to existing procedures.

She was also critical of a lack of flexibility to enable adequate staffing during a busy weekend with a number of high-acuity patients, and of the handover process that did not consistently support the sharing of important information such as medication allergies.

McDowell reflected on the devastating impact of the error on the woman’s family but noted this was human error by clinical staff who were also affected by the outcome.

“I note and agree with the comments of my independent advisor, Dr Margaret Wilsher, that it is accepted that hindsight allows clarity of perspective that foresight can never achieve.

“Humans by their very nature are fallible and can err, and work done is not the same as work imagined. In reality, clinical practice in a busy acute admitting hospital will mean that there is potential for distraction and interruption, for shortcuts and lack of adherence to process, so the system and its processes must be sufficiently robust to protect patients at such times.

“However, it is also important to recognise that individuals have professional responsibility in their practice, and that it is appropriate to hold individuals to account for departures from the expected standard of care.”

Te Whatu Ora Te Tai Tokerau accepted systemic factors contributed to the error and agreed electronic prescribing was key to preventing medication errors, saying it had requested this be prioritised for years.

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.