On Friday, news reported that a patient died of a stroke at St. Olav in December, and that the county doctor links the death to the Health Platform. The health platform is a new and common patient record for hospitals and municipalities in central Norway. In total, the State Administrator, via the Norwegian Health Authority, has received three different notices from St. Olav related to the introduction of the Health Platform. Employees in hospitals and municipalities are obliged to send notifications of serious incidents to the Norwegian Health Authority. They must notify of death or very serious injury to the patient, and this applies if this is unexpected based on the risk. The notifications are about: – We are concerned, says Ida Brenne Østhus, supervision coordinator at the State Administrator in Trøndelag. Since mid-November, St. Olav has had 15 alerts that have been reported to the Norwegian Health Authority, not all of which concern the Health Platform. On average, it is somewhat higher than it usually is. Patient died of a stroke In December, a patient was admitted to St. Olav for possible bleeding. The patient was at risk of stroke and was taken on blood thinners. Two days later, the patient was admitted with a massive stroke, and later died from this. Staff were unable to find information in the patient record as to whether the patient had been put on blood-thinning medication again, as he should have been. The notice from St. Olav states, among other things, the following: “Not sure how to improve the discharge procedure in the Health Platform, but this is critically difficult and has an extremely high risk of critical error that causes great patient harm as in this case”. – Basically, we see this as a possible serious consequence of the Health Platform, said county doctor Jan Vaage to news. The state administrator will start looking into the case on Monday. They want to know more about what has happened in a week at the earliest. Warnings: “Will be completely catastrophic for some patients” The second warning was received by the State Administrator on 20 December from St. Olav, and concerns patient treatment. A patient has been investigated for a long time, and the patient has possible malignant disease in the pancreas, says Ida Brenne Østhus, supervision coordinator at the State Administrator in Trøndelag. The patient was referred to Rikshospitalet for an assessment, but the referring doctor did not receive an answer. At first, the doctor internally tried to find out whether the referral had been sent out, but it was not possible to find out, says Østhus. The doctor then contacted Rikshospitalet, which received the message on the same day as the doctor urged. They thus received the referral four weeks after it had been sent. The supervisor links the case to problems with communication in the Health Platform. Usually, such a referral, which is sent electronically, must arrive immediately. “For some patients, this will be completely catastrophic, and will quickly lead to a loss of prognosis and premature death,” the superintendent writes in the warning. The doctor adds that the person in question is concerned about patient safety due to delayed communication and a lack of overview. Don’t know how things are going with the patient. The state administrator thinks the case is unfortunate. – When you send a referral, you expect that it will arrive, and in any case that you will be able to find out whether it has arrived or not. When the doctor in question tried to find out, he couldn’t. It’s not lucky, says Østhus. – What can happen when you have to wait four weeks longer than you should, when malignant disease in the pancreas is suspected? – It goes without saying that things can go wrong. We don’t know how this patient has fared, we won’t know that until later. But for others it can mean life, says Østhus. The state administrator has asked St. Olav for an explanation in the case. Ida Brenne Østhus is supervision coordinator at the State Administrator in Trøndelag. Photo: Jøte Toftaker / news Over 30 delayed test answers The third notice comes from the medical department for biochemistry at St. Olav and was sent on 27 December. They handle blood tests and blood test results at the hospital. It appears from the notice from St. Olav that both the laboratory at the hospital and the person who requested blood samples for a patient lack an overview. This has led to tests being overlooked and test answers being delayed. “.. In 30 cases, test results have not been reported within the expected time…” the notice sent on 27 December reads, among other things. There have been major challenges with messages between GPs and hospitals, including that the GPs have received illegible epicrisis and fewer epicrisis than normal. Supervisory coordinator Østhus says the State Administrator is concerned. They have received information from GPs that many people themselves are nagging in cases where they are waiting for test results which they suspect may be serious. – But you are not always very worried before you get the answer either, she says. GPs still worried In addition to the three notifications, the State Administrator has received what Østhus describes as many messages of concern. – It is especially from GPs and some from hospital staff, she says. The reports of concern relate in particular to problems with electronic messages between GPs and hospitals. Helse Midt-Norge said in its board meeting on 5 January that the situation surrounding errors in the Health Platform linked to electronic messages at the hospital was in the process of improving. The last notification the State Administrator has received about errors with electronic messages was 13 January, says the supervisory coordinator. They have an ongoing dialogue with the Norwegian Health Authority in the cases, Østhus concludes. Believes it is safe to be a patient Director Grete Aasved at St.Olav’s hospital will take a closer look at notices that have come in after the Health Platform was introduced. – For us, it is incredibly important to find the cause anyway, and we always do that in a structured way in collaboration with the State Administrator, says Aasved. She emphasizes that they are about the average in Norway when it comes to cases that are notified to the Norwegian Health Authority. – I want to emphasize that it is safe to be a patient at St. Olav’s hospital. We are keen to report what needs to be reported in order to learn and prevent, says the hospital director. Monitors all referrals Chairman of the Health Platform, Helge Garåsen, says that they now monitor all referrals, epicrisis, laboratory results and X-ray results. – We see that it gets where it needs to go. Errors are about to be closed, says Garåsen. It has still been a bit problematic with the reading format of epicrisis from the hospital to the GPs. Now the latest version of it is being tested, and it also seems to be working, he says. – What do you think that referrals from a doctor at St. Olav to the National Hospital have taken a month? – It is of course very unacceptable if the Health Platform is the direct cause. Now we have to wait and see what comes out of the investigations.
ttn-69
Patient was examined for cancer at St. Olav’s – referral came a month late – news Trøndelag
