Middlemore patient dies after medicine machine jams

Middlemore patient dies after medicine machine jams

An investigation has been launched into the death of a hospital patient after an automated dispensing machine fault delayed doctors access to vital medicine.

The Counties Manukau District Health Board (DHB) are looking into the incident which occurred in early 2020 at Middlemore Hospital's emergency department.

According to the DHB committee's report, the person was brought to the hospital by an ambulance after suffering a cardiac arrest.

On arrival, emergency department staff then tried to access medicine for the man from a dispensing machine but it had jammed.

"The Physix machine had a bag of magnesium fluid stuck between drawers, so medication could not be dispensed," the report says.

Automated dispensing machines are designed as a central point for distributing and accessing drugs in hospitals and medical facilities.

Each transaction is automatically recorded so staff don't have to manually count patient doses.

Chief Medical Officer Dr Peter Watson said the issue with the machine hadn't previously been identified by staff as the medication was not typically used during resuscitation, RNZ reported.

"In addition, all resuscitation drugs are available in the ED and other hospital wards without accessing a Pyxis machine."

The medication was instead gathered from ICU within 10 mins, but Dr Watson said the patient was "critically unwell" and later passed away.

"The patient died but the DHB is not entirely sure the machine fault is related to the death but a full investigation is underway."

The DHB is also conducting a review from an external expert who will provide a comment.

Once the investigation and review are concluded an alert will be put out to other hospitals that use the machine to alert them to the fault, Dr Watson said.

"To remove any vulnerability the pharmacy has put into place a number of improvements including the way the machine is stacked, training of the nursing team to access the rear of the machine, and storing of medications in multiple areas to avoid a single source of failure."

The machine's supplier is yet to be contacted. 

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