A baby was born with brain damage in a Queensland hospital after critical patient data was entered into different sections of its mother’s electronic medical record, meaning obstetricians were “unlikely” to have seen a key test result.
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A confidential case review of the early 2018 incident, seen by Brisbane Times, also identified poor communication between regional healthcare and hospital staff, lack of a complete medical history, staff fatigue, and a failure to use all available resources as contributing factors to the incident.
A Queensland Health spokesman said patient safety and care was always the department’s number one priority.
The baby’s mother, who was considered a high-risk patient, suffered short-term memory loss due to eclampsia, and her baby required ongoing specialist support.
The case review was conducted to identify what happened and how to prevent similar incidents in the future.
One of six recommendations made in the report was that the “disjointed information flow” in the integrated electronic medical record’s maternity module be flagged with eHealth Queensland as a “statewide issue”.
It also recommended that specialists such as endocrinologists and cardiologists be given access to sections of the obstetrics module in the integrated electronic medical record - part of which was considered “restricted access”.
A Brisbane Times investigation has found multiple patient safety risks with the software, with clinicians and health bodies repeatedly raising their concerns about the ieMR with Queensland Health.
A Queensland Health spokesman said in 2017-2018 the ieMR supported 6.8 million episodes of patient care.
The $600 million integrated electronic medical record (ieMR) project, run by eHealth Queensland, gives all patients an electronic medical record accessible by all clinicians at hospitals with the ieMR installed.
So far, 10 hospitals have the electronic medical record installed, with the Sunshine Coast University Hospital the latest to launch the software.
“Suggestions for improvements and changes to the ieMR from clinicians are a normal part of its operation, but there have been no reports made to eHealth Queensland of patient harm directly linked to the implementation of the ieMR,” the spokesman said.
The woman at the centre of the review was 38 weeks’ pregnant when she went to a regional health service with abdominal pain, vomiting and high blood pressure. She was discharged with antibiotics and a plan to return that morning for a check-up.
While at home, the woman suffered seizures. Rushed back to the health service by ambulance, the woman was intubated and ventilated, and flown to hospital for an emergency caesarean.
The confidential case review recommended the rural facility’s operations be assessed to make sure patients received proper communication and care.
It also recommended a urine test be conducted to check for protein in urine at every clinic, and risks be clearly communicated to pregnant women being treated at the clinic.
At one of the woman’s early appointments in December 2017, a midwife had entered the results of a urine test in the obstetric section of the ieMR, which noted a high protein level in the urine that could lead to pre-eclampsia and eclampsia.
Eclampsia is a serious condition that leads to high blood pressure and convulsions during pregnancy, and protein in the urine is an early warning sign of the potential for a woman to develop it.
Pre-eclampsia can cause growth delays in babies due to a lack of oxygen and nutrients.
The urine test result was not mentioned again in the patient’s electronic medical record when the woman returned to hospital in early 2018, the review found.
“The content expert on the team advised that it is likely that the obstetrician would not have seen the ward test urine results as the medical officers do not use ‘obstetric view’,” the report found.
The obstetric view was used by midwives in antenatal clinics to insert and edit test results and patient comments.
After birth, the woman’s baby was given three minutes of CPR and taken into intensive care.
The baby was diagnosed with brain damage needing specialist support, and was discharged after nearly three weeks in hospital.
The internal review of the 2018 incident found that clinicians used the incorrect assessment tools to monitor the woman’s symptoms, and she was not given a paper hand-held patient record when being transferred from a regional clinic to the hospital.
“The case review team agreed that the fragmented care was exacerbated by factors relating to clinical processes and there were a number of missed opportunities to identify the patient’s additional risk factors earlier,” the report said.
Midwives entered key patient information into "obstetric view", a section of the woman’s electronic medical records dedicated to maternity care.
However medical officers had been told not use that section as it was not easily seen by other specialists who might have been treating the patient.
Comments from midwives and test results that were entered into "obstetric view" would also go to another tab on the patient’s medical record, called "results view", the report said.
But the report found obstetricians did not use the "results view" tab as it was “considered incomplete”.
The Queensland Health spokesman said all systems, including paper-based systems, had risks.
“Patient safety experts and the vast majority of clinicians across Queensland agree that the benefits of the ieMR far outweigh the risks,” he said.
In September 2018, the Australian Medical Association Queensland wrote to Queensland Health director-general Michael Walsh highlighting the issue of clinicians unable to see critical patient data because it was entered into different sections of the ieMR.
The case review recommended that the way midwives and obstetricians used the ieMR be altered to ensure all patient information could be seen by all clinicians, including specialists such as cardiologists.
Those recommendations were passed on to eHealth Queensland and the department.
Queensland Health has been upgrading the obstetric module over the past 18 months, rolling out 36 upgrades including the ability for anaesthetists to see "obstetric view".
The incident followed an August 2017 obstetric safety alert issued to hospitals by an eHealth Queensland project manager on the ieMR.
Safety alerts are issued when the software malfunctions and may be a risk to patients.
The alert warned about a “patient safety risk” as an alert system that monitored how a pregnant woman’s labour was progressing did not work correctly.
Without the “action and alert” system, midwives and clinicians could not accurately monitor how a woman’s labour was progressing on the electronic medical record and whether they needed to intervene, for example by performing a caesarean section.
Cerner, the US medical technology company contracted to provide the ieMR software to Queensland Health, could not fix the problem, the letter said.
Instead, the “action and alert” system had to be turned off completely.
Changes made to the partogram since included the ability for historical charts to be seen, and the signature of the last treating clinician added to each patient’s record.
Do you know more? Contact Brisbane Times at brisbanetimesinvestigates@protonmail.com
