Finding into death of H D

Contributing factors

• Pharmacy data entry error duplicating similarly-named resident's medications
• Rushed transition from paper-based to electronic medication system
• Transition scheduled proximate to public holiday period
• Single person data entry at remote pharmacy without independent verification
• General practitioner did not independently verify pre-filled electronic chart against original paper chart
• General practitioner time-pressured and depended on pharmacy printouts rather than original charts
• ACF staff did not cross-check new medication packs against original paper-based charts
• Lack of robust reconciliation process within 24 hours of electronic go-live
• Inadequate governance and planning for system transition
• Multiple failures across multiple parties allowed error to persist undetected for one week

Coroner's recommendations

1. Governance systems around introduction of electronic medication charts should be planned in advance and include appropriate staff education
2. Mapping of sequential tasks of pharmacist, medical practitioner, and administering staff should be completed before implementation
3. Introduction of new technology should not be conducted during or proximate to known public holiday periods due to lack of staffing and resources
4. Medication transcribing tasks should be performed in the clinical setting by more than one person, not at a remote pharmacy with a single person
5. Further reconciliation of new electronic medication charts should occur within the first 24 hours after electronic go-live
6. Medical practitioners should be aware of their overarching responsibility in signing electronic medication charts and should not rely on pharmacy staff to pre-fill orders
7. Continued vigilance regarding medications during transition periods
8. Finding to be distributed to relevant organisations including Royal College of General Practitioners, Pharmacy Guild, Society for Hospital Pharmacists, and Aged Care Quality and Safety Commission to raise awareness of heightened risk during electronic system transitions