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8 NOVEMBER 2024 ausdoc . com . au

‘ Input error ’ led to fatal overdose

Coroner Ken Archer .

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Paul Smith A CORONER has blamed an “ input error ” involving handwritten medication charts for the death of a patient from a paracetamol overdose administered following her surgery .

Sharyn Kaine , who weighed 39kg , was originally taken by ambulance to Calvary Hospital in Canberra with a perforated bowel on 2 October 2021 .

The persons depicted are models used for illustrative purposes only .

Sitthixay Ditthavong © The Canberra Times / ACM

Before surgery , a surgical registrar prescribed her a 1g dose of paracetamol qid to be delivered intravenously .

The ACT Coroner ’ s Court was told that , when the anaesthetist saw the script , he cancelled it because of Ms Kaine ’ s weight , handwriting the change to 600mg qid .

Following surgery to repair her bowel , she was transferred to the ward where her medications were

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The junior doctor told the inquest that she did not see the anaesthetist ’ s handwritten change and did not know whether the change had occurred before or after entering the medications and doses into the electronic system .

“[ The junior doctor ] also noted that 1g of paracetamol qid is a standard dose and there was nothing in the records to indicate that there was any abnormality in her liver function results to indicate that a prescription at that level was causing adverse outcomes ,” ACT Coroner Ken Archer said .

“ It was her understanding that , once the medications were charted , the

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The junior doctor did not see the anaesthetist ’ s handwritten change .

general surgical home team and acute pain service would review the patient ’ s charted medications .”

He said , over the following five days , the 1g paracetamol dose was administered intravenously on 13 occasions .

Ms Kaine , 73 , collapsed on 7 October and was admitted to ICU , with doctors believing septic shock to be the cause .

Dialysis was initiated , but her condition deteriorated , and she died 24 hours later .

The Coroner found that she had died of multiple organ failure due to adhesions related to bowel perforation and paracetamol-induced liver failure .

Both the junior doctor and the surgical registrar told the inquest that they did not consider whether the 1g qid prescription was appropriate .

“ It is unclear what [ the junior doctor ] could see when she was entering information into [ the ] EMM , but the EMM record shows the patient ’ s details at the top of the page , including [ her ] weight ,” Mr Archer wrote in his findings . “ One assumes that the EMM did not have the capacity to identify the inappropriateness of the [ dose ] and alert the prescriber / data entry officer that further consideration might be required .”

The Coroner also said there seemed to be no review of the doses while Ms Kaine was on the recovery ward — in part because the “ warning functionality ” within the EMM was not sufficiently robust .

“ It appeared that the first liver function testing postsurgery was carried out on 6 October , and further testing , as well as an INR test , was done on 7 October … By that stage , the liver had shown significant dysfunction .” Following the incident , the hospital replaced both the MedChart and the National Inpatient Medication Chart with the ACT ’ s Digital Health Record : a record of all interactions between a person and the territory ’ s public health system .

The Coroner said : “ Sharyn ’ s case … involved an input error but in a ( largely ) pre-digital prescription and [ dose ] monitoring environment .”