Health and disability commissioner warns of life-threatening gaps in hospital digital systems

NEWS - eHealthNews.nz editor Rebecca McBeth 

The continuing use of paper-based referral and prescribing systems in hospitals is compromising patient safety  and reveals critical gaps in New Zealand's digital infrastructure, the health and disability commissioner says.

Speaking at Digital Health Week 2025, Morag McDowell said disparities in access to electronic prescribing systems across the country are leaving some facilities without basic digital drug alert capabilities.

She highlighted the case of a cardiac surgery patient with a documented penicillin allergy who suffered life-threatening anaphylaxis because of inconsistent allergy documentation across multiple hospital systems.

"When the HDC did its investigation, the documentation of the allergy on the national medication chart was very inconsistent and there were multiple errors throughout the clinical records, across multiple staff members and across multiple teams about his allergy status," McDowell said in her keynote address.

The investigation found the failures represented a systemic breach of patients' rights to services of a reasonable standard and the hospital has since developed a new single patient management system with electronic drug alerts.

In another case, a GP's paper referral letter expressing concerns about possible subacute bacterial endocarditis was lost, so was not seen by the treating clinicians.

"Evidence to the investigation showed that the GP to hospital referral system had been something of an issue for years for which no sustainable solution had been found," the commissioner told attendees.

The lost referral was a missed opportunity for timely diagnosis and resulted in breach findings for both reasonable standard of care and cooperation among providers to ensure continuity of care.

Digital systems that do not talk to each other are also adding risks, such as a case where a patient with bowel symptoms and an identified pelvic mass had their care delayed because of lack of integration.

"There had been a business case put forward about 10 years earlier for system integration which regrettably had been declined due to cost and time," McDowell said.

She also told the conference that patients have rights to informed consent regarding AI, telehealth, and other digital tools. Providers must explain why tools are being used, their benefits, limitations, risks, and mitigation strategies, plus any alternative options.

"People do have the right to decline their use, but of course should be told of the risks of doing so," she said, adding that digital tools such as AI cannot substitute for clinical judgement, and providers retain responsibility for decisions made and actions taken.

"Please read those AI notes, double read the AI imaging, reflect on the diagnosis," said McDowell.

Image: Health and disability commissioner Morag McDowell speaking at Digital Health Week 2025

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