Deputy Health and Disability Commissioner Dr Vanessa Caldwell today released a report finding Hutt Valley District
Health Board (HVDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for its
inadequate processes to manage information about allergies and communication with a general practice.
In this case, a man was being treated for an injury while on holiday and there was no alert on the National Medical
Warning system of a potential allergy to flucloxacillin that had been evident in a previous visit at his home DHB only
three weeks prior. Subsequently, he was treated with flucloxacillin intravenously and sadly died of anaphylactic shock
shortly afterwards.
Deputy Commissioner Dr Vanessa Caldwell considered that his home DHB, HVDHB, had an inadequate system for ensuring that
allergies were recorded and flagged in the National Medical Warning System (MWS), and for its inadequate communication
with the man’s usual general practice.
The National MWS is an alert service linked to the patient National Health Index numbers, and is designed to warn health
and disability support services of any known risk factors that may be important when making clinical decisions about
individual patient care.
"The purpose of the MWS is to warn health and disability support services of any known risk factors such as allergies
that may be important when making clinical decisions about individual patient care. The system has been linked to
patient National Health Index numbers so that these alerts can be accessed and viewed throughout New Zealand.
"The responsibility for maintaining the content of the MWS rests primarily with healthcare providers. However, currently
there is inconsistency in the way in which warnings are managed, with each DHB having adopted its own processes and
delegations as to what notifications can be added and by whom.
"This case is an example of the weaknesses that exist within the current system. Without doubt issues with the national
system contributed to these events, I nonetheless consider it vital for individual medical centres and DHBs to have
their own adequate systems and processes in place for drug and medication allergies, to ensure that staff are supported
adequately in their decision-making and reporting requirements," said Dr Caldwell.
In her report Dr Caldwell reminded HVDHB of the importance of ensuring that all communication with patients,
particularly in relation to advice as vital as allergy information, is fulsome and documented, and that patients have a
good understanding of the implications.
"The Code gives people the right to effective communication, and the right to be fully informed. Healthcare
professionals are required to communicate clearly to their patients in a way that allows the patient to fully understand
the information being provided," said Dr Caldwell.
Dr Caldwell recommended that the medical centre undertake an audit to ensure that important information in patient
discharge summaries received are being actioned, and that the HVDHB undertake intermittent audits of whether their
policies relating to new allergies that require action are adequate and observed.
She also recommended that HVDHB develop an end-to-end process for both the ED and general hospital setting for when a
patient presents with, or experiences, a new actual or suspected drug/medication allergy, as well as recommending that
they design and implement a new discharge form, and create a package of educational material to be used throughout
departmental teaching sessions and staff inductions to address general standards of practice expected in relation to
medication allergy reporting and follow-up actions.
The full report of case 19HDC02039 is now available on the HDC website.