'Numerous' prescription errors
A surgeon at Southland Hospital has acknowledged that prescription and dispensing errors in the hospital are numerous and of great concern, a coroner says.
Otago Southland coroner David Crerar made the comment in his formal written findings into the death of Wilhelmus Antonius Brocks, 80, of Wyndham, who died in Southland Hospital on May 2, 2011.
Mr Crerar said Mr Brocks was given the wrong dose of medication before his death.
"The evidence establishes, to the standard of proof necessary for a coroner in such cases, that Mr Brocks was prescribed and took warfarin at doses which were greater than ideal.
"In spite of checks established at Southland Hospital to avoid such occurrences, Dr Fosbender [Southern District Health Board surgical directorate medical director Murray Fosbender] acknowledged that prescription and dispensing errors in hospital are numerous and are of great concern," Mr Crerar said in his findings.
Mr Brocks was admitted to hospital on April 16, 2011.
A three-week history of breathlessness and a cough was reported. His medical history included coronary artery disease and chronic obstructive airways disease and he had been taking warfarin.
Warfarin is an anticoagulant that reduces blood clots.
After Mr Brocks was discharged, he told his daughter his dosage of warfarin had increased while he was in hospital from 1mg (five tablets once a day or as advised) to 5mg a day in one tablet, the findings say.
A blood test on April 28 revealed he had a high level of warfarin, which was above 10, and he was called by his doctor and given vitamin K to reverse the effects of the drug.
Mr Brocks' condition deteriorated that evening and he was again admitted to Southland Hospital, the findings say.
A scan showed a significant brain bleed.
On May 2 he suffered a cardiac arrest.
Mr Crerar, while emphasising the fact that the warfarin overdose was a contributor to the death and likely caused a greater volume of bleeding, said there was no evidence to convince him the warfarin overdose caused the haemorrhage "Indeed, the evidence I prefer is that it did not."
The district health board had made appropriate apologies to the family, he said.
Mr Brocks' death also identified the lack of a continuous blood-testing service in Southland.
The board and its contractors should consider the establishment of even a limited, after-working-hours, blood-testing service to avoid delays, Mr Crerar said.
Mr Crerar also pointed to the medical profession using too many acronyms and abbreviations.
"The Southern District Health Board, and health professionals generally, could consider a simplification of description and a more generalised use of the English language."
- © Fairfax NZ News
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