The involvement of fax communications in a referral mix-up at Auckland City Hospital which led to the death of a patient is adding to the pressure for purely electronic communication of medical information.
Health and disability commissioner Ron Paterson recently released a finding which concluded that a medication mix-up caused by an obscured fax page led to the death of patient Mervyn McAlpine in 2004.
The finding has led health minister Pete Hodgson to urge the wider adoption of electronically readable barcodes identifying the patient on prescriptions and medicine containers.
The fax software involved in the 2004 incident has since been appropriately updated, says the vendor, MedTech. The Royal College of General Practitioners also says its investigation of such vulnerabilities has been completed and appropriate remedies put in place, but plugging all the potential holes is more complex than might be supposed, a spokesman says.
When McAlpine’s GP referred him to the hospital, a single-page fax was sent from the GP’s MedTech 32 software package with the patient’s details. The fax emerged on paper at the hospital and was paper-clipped and subsequently stapled together with concurrently faxed notes relating to another patient. This led to McAlpine being given the other patient’s medication, which proved fatal.
The stapling obscured header information that could have revealed the mix-up, says health and disability commissioner Patterson’s report.
MedTech 32 did not, at the time of the incident, have the ability to generate page numbers or cover-sheets on its faxes, says Russell Clarke, executive director of MedTech Global. This was remedied in an update released in April last year.
It is “at the discretion of the GP” to generate fax cover sheets, and this can be done in an independent program such as Microsoft Word, Clarke says.
The Royal NZ College of General Practitioners also became involved and has made sure appropriate fixes were put in software packages that lacked the pagination and cover-sheet ability.
MedTech claims 75% of the New Zealand GP market, but other products have also been examined and fixed.
The mishap has intensified pressure for a purely electronic system of referrals and for issuing prescriptions, a need that was flagged in a Health Information Strategy published by the Ministry of Health in 2005.
“Replacing paper-based referrals with electronic messages would no doubt have a financial benefit,” says the strategy document, “and there are non-financial benefits in the timeliness with which information is received and resulting actions taken. A coherent strategy is required to maximise the benefits of broadband to the sector.”