Finding into death of Ian Fraser

68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration of the anticoagulants apixaban and enoxaparin

Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mistakenly ordered it as an inpatient medication, then cancelled the wrong order, leaving both medications active. The patient received both drugs before transfer, leading to severe bleeding. Key lessons: Electronic Medical Records (EMRs) with poor usability design contributed critically to this preventable error. The prescribing interface displayed both inpatient and discharge medications on the same screen ('mode confusion'), lacked alerts for duplicate drug classes, and had unclear icons. Staff training alone cannot overcome poor interface design. System solutions require vendor collaboration, regulatory oversight, and standardised usability testing. Health services need TGA regulation of EMR software as medical devices with mandatory usability compliance, not just local workarounds.