HDC says DHB’s weak IT systems a “major risk to patients”

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eHealthNews editor Rebecca McBeth

The inability of Wairarapa DHB’s IT system to allow for electronic sign-off of results presented a major risk to patients, a new report from the Health and Disability Commissioner says.

The report identifies a weak and aged IT system as key to the DHB failing to provide an elderly man with reasonable care and skill, and therefore that the Commission found the board had breached the Code of Health and Disability Services Consumers’ Rights.

It details how DHB staff did not pick up on the man’s cancer symptoms for several months because the DHB did not have a clear, effective and formalised system in place for the reporting and following up of test results.

“The inability of Wairarapa DHB’s IT system to allow for electronic sign-off was a critical system and practice failure. It presented a major risk to patients … important and significant results could be easily missed under this system,” the report says.

The DHB upgraded to the webPAS patient administration system from DXC in January of this year as part of the Regional Health Informatics Programme and is working on implementing electronic sign-off, but could not say when the new functionality will be live.

The HDC case involves a 72-year-old patient who was admitted to hospital in March 2016 after a fall and had a CT scan of his chest, abdomen and pelvis. The final scan report identified enlarged lymph nodes and the radiologist suggested endoscopic examination to rule out a rectal tumour.

This was entered as a ‘sticky note’ on the Picture Archiving and Communication System, but another sticky note was entered after that which did not mention the nodes and meant the first one was not immediately visible to staff.

The patient was then discharged and the initial report was not seen until November that year and the man was later diagnosed with Stage III cancer.

“There was no alert system to notify a doctor that a result had arrived, nor was there a doctor-specific list of results to review,” the HDC report says.

“Clinicians had to proactively look up the results of tests they had ordered, on an individual patient basis. Wairarapa DHB acknowledged that this was a significant weakness in its system and, until this could be improved, there was no protection from recurrence.”

3DHB chief information officer Shayne Hunter says the systems in place at Wairarapa now enable electronic sign-off.

“The recent upgrade of webPAS has been a key component of this work, and we have also made changes to Concerto – the primary ICT tool used by health professionals – to support electronic sign-off of laboratory results,” he says.

“This work, which includes looking at how to implement electronic sign-off into clinical practice, is ongoing, and it is currently too early to indicate when it will be completed.”

The HDC report also emphasises that sticky notes should only be used as a preliminary reporting tool that answer immediate clinical questions and “should not be relied on in place of the final report”.

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