Health Investigation – Patient medical warnings must be captured safely, report highlights

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Vanessa Caldwell today released a report highlighting the importance of capturing patient medical warnings safely, after a man suffered an adverse reaction to radiography dye.
The man, in his eighties at the time of events, was diagnosed with cancer of the blood and bone marrow, and treated with chemotherapy. He required CT scans, which involved iodine contrasts. After the third scan, his GP recorded a reaction to iodine contract in the man’s Medical Warnings in the GP Practice Management System and this was provided with referrals to the District Health Board (DHB).
Although no breach of the Code of Health and Disability Services Consumers’ Rights was found in this case, the Deputy Commissioner found that the man’s adverse reaction to the contrast dye should have been added to the DHB’s systems in the first instance.
Dr Caldwell also noted that the man’s allergy was not entered on the National Medical Warning System by any health provider.
“The report highlights the importance of adequate communication between providers (in this case GP to DHB) to capture patient medical warnings safely,” said Dr Caldwell.
“There is an opportunity to align expectations and systems better across the primary and secondary sectors at a national level to improve the quality and safety of health services.”
Dr Caldwell will be writing to the Ministry of Health to request an update on progress on improvements to the National Medical Warning System.
She recommended that the DHB provide an update on its work to develop an interface between the GP e-referral system and the DHB’s radiology system, and consider whether there are additional measures the DHB can take to improve reconciling of GP e-referral medical warnings with its radiology system.