An allergic reaction to flucloxacillin
Introduction
This case is one where a patient died from an anaphylactic reaction and although general practice was not involved in the case, they still received a reprimand and were required to apologise to the patient’s family.
The case
A middle-aged man developed an infected toe and decided to take some flucloxacillin (which had expired) that had previously been prescribed for another family member and was available in the house. He quite quickly developed an anaphylactic reaction and was taken to the Emergency Department (ED) in the Hutt Valley (HVDHB) where he was treated and discharged with a prescription for topical antibiotics. The Commissioner felt that this was appropriate treatment.
Three weeks later he became unwell again with another toe infection while he was travelling and away from home. He presented to another medical centre where staff felt that he was sufficiently unwell that they sent him to the ED of their DHB. He was repeatedly asked if he had any allergies and he repeatedly denied that he had. He was given IV flucloxacillin, suffered a severe anaphylactic reaction and subsequently died.
Breaches of the HDC Code
The breaches of the HDC code were identified as:
- Although the patient was informed by the ED officer at HVDHB ED that his allergy was likely due to flucloxacillin, the patient was not given written advice. However, in the case notes there was a reference to “advised possible allergy to flucloxacillin.” The actual diagnosis in the case notes was “allergic reaction NOS.” The family acknowledged that they were told of the probable allergy but obviously did not understand the implications.
- The potential drug allergy was not added to the national Medical Warning System (MWS), or to the first DHB’s (Hutt Valley) own drug alert system. It appears the second DHB did interrogate the national system but found no warnings, or any references to the Hutt Valley DHB’s ED 21 days prior. The second DHB hospital specifically noted that the patient had no known allergies.
Medical Warning Systems (MWS)
The MWS is a national database accessible to all DHBs, but not to general practice. The first ED officer (at Hutt Valley DHB) was not aware of how to enter data onto the MWS, and the HVDHB acknowledged that they had no policy or protocols on how to use it. The Ministry of Health acknowledged that there was no centralised governance of the MWS and that DHBs had varying ways of dealing with the data. There is one possible way that general practice can input information on the database and that is by reporting an event to the Centre for Adverse Reactions Monitoring (CARM) who will then update the MWS database. The Ministry have now set up a MWS Working Group.
The patient’s medical centre
Throughout this tragic series of events, the patient’s medical centre was not involved other than when they were sent a discharge summary from the HVDHB ED. This was transmitted electronically but was incorrectly headed so it went into an “unmatched” inbox which was subsequently filed by a practice nurse without it being passed on to the patient’s own doctor (who was on leave at the time). The Commissioner acknowledged that the diagnosis was vague, and that no specific instructions were given to the practice.
The Commissioner has criticised the medical centre for not having a policy to deal with unmatched files, along with a system of adding known allergies to the practice’s database.
The Commissioner has directed the Centre to apologise to the patient’s family.
As an aside, there appears to have been no requirement by the Ministry of Health to apologise for developing an alert system and then not managing it appropriately.
Learnings
Allergies need to be carefully documented with appropriate notes to ensure the patient understands the implications of the diagnosis. You also need to be aware that unmatched results need to be dealt with in accordance with a practice policy.
Even though you or your practice may not be directly involved, you can still find yourself criticised by the HDC.
