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Anaesthetist censured for fatal drug mix-up

Spike in mandatory reporting of doctors - Featured Image

A 54-year-old man died after he was prescribed the wrong medication when he went to a Sydney hospital for routine surgery, a coroner has found.

Paul Lau expected to be discharged from Macquarie University Hospital a day after his knee reconstruction in 2015 but the father-of-two died when he was mistakenly given the medication of another patient.

Acting State Coroner Teresa O’Sullivan on Thursday said anaesthetist Dr Orison Kim didn’t exercise proper care and diligence when he entered the incorrect drugs into Mr Lau’s electronic prescribing record.

The anaesthetist has accepted that a patient’s name was always displayed on-screen and he overrode 22 alerts to enter the prescriptions, an inquest at Glebe Coroner’s Court heard.

In the hours that followed, Dr Kim and other hospital staff missed opportunities to detect the serious error and save Mr Lau’s life, despite his high dose of opiates being very unusual for such a patient.

The coroner said the “most serious failure in critical thinking” occurred when Dr Kim checked in on Mr Lau after the surgery and realised he was receiving two drugs he hadn’t prescribed.

Instead of checking Mr Lau’s medications, the anaesthetist assumed a doctor must have pre-operatively prescribed the drugs for Mr Lau’s chronic knee pain despite there being no record.

The coroner said nursing staff also failed to question the prescription despite it not being mentioned during handover and did not adjust their care to reflect the risks posed by the medication.