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CASE STUDY:
Lack of consistent approaches
to prevention of thromboembolism
In 2011 at a private hospital, a 64-year-old
man had a mini-laparotomy to remove his
kidney, which had developed a malignant
tumour. He was given anticoagulants
after this procedure. A few days later he
was admitted to a public hospital because
of dehiscence of his surgical wound.
Sadly and unexpectedly fi ve days later,
he died in hospital as a result of a
pulmonary embolism (PE).
Senior staff met with the family to discuss
the events and acknowledged some
shortcomings, and proposed changes.
The family complained to the HDC that
despite numerous PE risk factors, the
man was not given a further course of
anticoagulants at the pubic hospital.
The family want to ensure that all
surgical wards in the hospital review
their processes.
The Commissioner obtained the opinion
of an independent surgeon, who observed
that there was no evidence of formal
risk stratifi cation, but it was evident
that the registrar did consider the
man’s risk of thrombosis. He explained
that the registrar was mistaken in that
thromboprophylaxis would lead to a
signifi cantly increased risk of
bleeding (given the patient’s abdominal
bruising), but noted this is a commonlyheld
misperception.
The expert considered that, according
to more modern practice, the man
should have been on prophylaxis for
one month following the procedure
at the private hospital.
The expert commented that there is a
large variation in thromboprophylactic
practice amongst district health boards,
and noted that all disciplines bring
expertise to the question of
prevention of thrombosis.
CASE STUDY:
Use of unapproved medication to
perform dermal fi lling procedure
A woman consulted a medical practitioner,
wanting a cosmetic procedure to help
her achieve a healthier appearance. He
recommended a procedure called the
“mid-face volumisation”, which involved
the injection of a dermal fi ller into her
cheeks. The product he used as the dermal
fi ller (the product) was not an approved
medicine in New Zealand under the
Medicines Act 1981.
The medical practitioner informed the
woman that the product included the
same chemical compound that he had
been using for the previous four years,
and that he had considerable experience
performing the procedure, but did not
inform her that the product was not
approved in New Zealand. The medical
practitioner did not inform her about the
possible side effect of granuloma formation.
Following the procedure, the woman
developed granuloma formations, which
the medical practitioner was unsuccessful
in treating.
It was held that the medical practitioner
failed to ensure that the product was safe
and appropriate for use as a dermal fi ller
HDC ANNUAL REPORT 2012
The Deputy Commissioner sent a copy
of the expert opinion to the district
health board and asked it to report back
on the steps taken across all wards of
its hospitals to involve all disciplines
in the education and prevention of
thrombosis. The DHB was also asked to
report back on its own initiatives, which
included use of a stamp to direct the postoperative
management of thrombosis
risk, amendment of the Admission to
Discharge planning document to include
a thrombosis risk assessment, and revision
of the prescribing charts to include a
separate thromboprophylaxis section.
Copies of the complaint and the expert
opinion were sent to the Health Quality
and Safety Commission, and the
Commissioner provided endorsement
for the venous thromboembolism
(VTE) prevention quality improvement
initiatives proposed by the VTE
Prevention Group.
and failed to provide adequate follow-up,
breaching Right 4(1) of the Code. He did
not provide the woman with information
about the risk of granuloma formation or
independent clinical literature about the
product’s safety, or tell her that the product
was not an approved medicine in New
Zealand, breaching Rights 6(1) and 7(1).
The medical practitioner was also found
to have inadequate documentation and
therefore breached Right 4(2) of the Code.
He was referred to the Director
of Proceedings.
(10HDC00986)
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CASE STUDY