Stimpson, Reginald - Non-inquest findings

Contributing factors

• Medication error: dual anticoagulation (Clexane and Xarelto) administered inadvertently
• Failure to properly cancel Clexane on medication chart when transitioning to Xarelto
• Inadequate nursing staff education on novel anticoagulants (Xarelto)
• Poor communication and handover between medical and nursing staff
• Split nursing responsibilities for oral versus subcutaneous medication administration
• Nursing staff unaware that Clexane and Xarelto should not be given together
• Lack of systematic checks for drug interactions and duplicate therapy
• Two separate medication charts for anticoagulants contributed to oversight
• Assumption-based practice: NUM assumed physician had cancelled Clexane; RN assumed overlapping was permitted as with Clexane-Warfarin
• Insufficient initial post-operative anticoagulation prophylaxis (aspirin only prescribed)
• Inadequate escalation of care when patient showed signs of deterioration on 20-25 March
• Patient discharged from ICU prematurely despite ongoing hypoxia and tachycardia
• Lack of post-operative complication clinical pathway

Coroner's recommendations

1. Physician group to review clinician handover and documentation processes; develop Medical Consultation handover form
2. Implement nursing staff education sessions on novel anticoagulants hospital-wide
3. Revise nursing medication competency to include novel anticoagulant-related questions
4. Nursing staff involved in medication errors to complete NPS medication safety package online
5. Include 'checking when two drugs with same indication prescribed' in Traffic Light Medication Safety System
6. Review inpatient medication chart and consolidate anticoagulant orders; separate chart into anticoagulants/antiplatelet and heparin infusion sections
7. Introduce process where one nurse completes full medication round and administers all drugs for allocated patients
8. Develop and implement Cognitive Impairment risk assessment tool with family notification triggers
9. Review and develop surgical post-operative complication clinical pathway with appropriate monitoring
10. Educate nursing staff on regular observation of vital signs overnight with escalation via MET call when applicable
11. Implement process where high risk drugs, including anticoagulants, are not stored as extra stock on wards
12. ICU to review step-down/discharge criteria for unwell patients no longer requiring ICU-level care
13. Pharmacy to review process for high risk drug education
14. Review VTE risk assessment tool to include surgical high risk factors while complying with NHMRC guidelines
15. Review and implement High Risk Medication Policy and communicate to all nursing staff
16. Communicate correct process for cancelling medications to all visiting medical officers with visual examples