Finding into death of Carlene Margaret Salveson
Deceased
Carlene Margaret Salveson
Demographics
80y, female
Date of death
2018-11-14
Finding date
2021-06-10
Cause of death
pulmonary thromboembolism in the setting of deep leg vein thrombosis; squamous cell carcinoma of the left pyriform fossa (treated)
AI-generated summary
An 80-year-old woman with treated squamous cell carcinoma of the pyriform fossa died from pulmonary thromboembolism secondary to bilateral deep vein thrombosis. She was admitted to hospital with poor oral intake, dehydration, and acute kidney injury following chemotherapy and radiotherapy. Critical risk factors for venous thromboembolism were present: age, cancer, dehydration, immobility, and hospitalisation. Alfred Health failed to prescribe pharmacological DVT prophylaxis despite having a management plan requiring it. The failure was attributed to implementation of a new Electronic Medical Record system on the ward which lacked appropriate decision-support alerts for VTE prophylaxis at go-live. Compliance with VTE prophylaxis dropped post-implementation. The coroner found this represented a missed opportunity to intervene, though could not definitively establish preventability. System failures in EMR implementation rather than individual clinician error were the primary contributing factor.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- failure to prescribe VTE prophylaxis despite high-risk status
- new Electronic Medical Record system implementation without appropriate decision-support alerts
- reduced compliance with VTE prophylaxis following EMR go-live
- cancer diagnosis and treatment
- dehydration and acute kidney injury
- reduced mobility
- prolonged hospitalisation
- advanced age
Coroner's recommendations
- The Chief Digital Health Officer of Victoria should coordinate with clinical and safety leaders in Victoria and nationally, including Safer Care Victoria, the Australian Commission on Safety and Quality in Health Care and Therapeutic Goods Administration, to review how Electronic Medical Records and Electronic Medication Management systems present and manage high-risk medicines
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