The only constant is change

Medical practice is undergoing rapid change, not only due to technology but also due to constrained resources. Regulators are loosening the buckles, enabling a wider scope of healthcare delivery through processes such as standing orders and the use of alternative care providers. However, with this expanded scope comes risk, and it is incumbent upon health professionals to fully understand these risks and how they can best be mitigated.

In an HDC case in August this year, standing orders were not followed, resulting in a catastrophic cerebral hemorrhage.

Recently, pharmacists have been empowered to take over the responsibly of managing warfarin under a system called CPAMS (Community Pharmacy Anticoagulation Management System). The system is supported by a computer program that provides an algorithm to calculate the recommended dose based on INR results. It operates as a standing order with a flow chart that notes the GP will receive a notification if the INR result is outside the safe range. This will occur provided the GP’s email address is set up correctly (which in this case it was not). The standing order requires that the software system will both notify the GP when the result is abnormal and seek confirmation that medical advice has been sought.

In this case, the INR was dropping below normal, so the dose of warfarin was increased. The next INR was significantly above the recommended range. Undated notes containing a recollection of the events by the pharmacist state that he advised the patient to be careful regarding any bleeding, to withhold warfarin for two days, and to return for a blood test (INR) in a week. The patient developed headaches and his condition deteriorated, and he subsequently died due to a brain hemorrhage.

The HDC concluded the pharmacist took action based on his own opinion and did not follow the standing orders, which state that the pharmacist must ensure that a medical review occurs. By failing to follow standing orders and failing to adequately document his rationale for treatment, he breached Right 4(1) [14] of the Code of Health and Disability Services Consumer Rights.

Andrew Dunn

General Practitioner