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A 'weak IT system' involving a missed sticky note at Wairarapa DHB led to a patient's rectal carcinoma, or rectum cancer, being missed for eight months.

In March 2016, a 72-year-old man presented to an unnamed public hospital. He had fallen three metres and injured his left hip and left side of the chest.

He was given an urgent CT scan of his chest, abdomen and pelvis and admitted to the surgical ward.

Paolo nutini new shoes download mp3 free. A radiologist accessed the images directly and, along with fractures from the fall, noted prominent lymph nodes around the rectum with an unknown cause. This was noted using a 'sticky note' in the Picture Archiving and Communication System (PACS) used at the DHB.

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Twenty minutes later, a second radiologist was working through the list of acute cases in and typed a sticky note on the patient's file that did not mention the rectal nodes.

Both notes would have been visible immediately, but the second note would have been on top, when accessing the patient's record in PACS.

The emergency department (ED) acted on the second note, which didn't mention the rectal lymph nodes and the patient was given pain relief and transferred to the surgical ward for ongoing care.

FINAL REPORT MISSED

The next day, the full report of the CT scan, with the rectal lymph nodes noted, was entered into the IT system.

The doctor in charge of the surgical ward (Dr C) was not aware of the final report and not aware of anyone having seen it after the patient was admitted to the ward.

Because he was not the practitioner who ordered the test, Dr C wasn't given a paper copy of the report and he did not review the final electronic version of the CT scan.

The patient was discharged three days later and the discharge summary from the surgical ward quoted the electronic note which left off the rectal nodes.

The ED discharge summary also quoted the note which left off the lymph nodes and didn't quote the final CT scan.

Results were then sent to the patient's general practice. The practice told the commissioner that any result ordered in an ED setting is assumed to have been dealt with appropriately by the inpatient team.

Over the next eight months, the patient repeatedly came back to the practice with bowel complaints, bloating, irritation and significant weight loss.

He was seen by several GPs and, in October, a GP noted a rectal mass on examination.

The GP referred the patient for an urgent colonoscopy and blood tests which led to the diagnosis of a stage IIIA squamous cell cancer requiring chemo-radiotherapy treatment and surgery.

NO ALERT FOR DOCTORS

At the time of the events, Wairarapa DHB's IT system didn't allow electronic sign-off for test results.

There was no alert system to let doctors know a result had arrived and clinicians had to proactively look up the results of tests they ordered.

Commissioner Anthony Hill found the DHB to be in breach of the Code of Health and Disability Services Consumers Rights for failing to provide services with reasonable care and skill.

The DHB is to update the commissioner on the progress of an IT system upgrade which will allow for electronic sign-off.

If sticky notes are still being used under the new IT system, the commissioner wants to know what measures have been taken to make sure they are only a preliminary reporting tool and that final reports are seen.

The DHB is also to audit its management of tests ordered at ED where patients are transferred to another ward.

Since the event, the medical centre has changed its own policy and now phones patients with complex discharges from hospital to check whether everything relating to the patient's admission has been dealt with.

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- New Zealand Doctor

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