Transcription error in patient record ends in tragic medication overdose

Errors in charting and administering medication can have serious consequences. The tragic death of a patient who suffered a paracetamol overdose highlights the importance of taking care in transcribing, and in implementing checks to minimise the risk of human error.  

Ms K was a 73 year old woman with a history of pancreatic cancer. She was admitted to the hospital with lower abdominal pain, weighing 39 kilograms. She underwent surgery for a suspected bowel perforation, which initially appeared successful, and her condition stabilised post operatively. 

However, four days later, Ms K’s condition rapidly deteriorated. A paracetamol overdose was suspected, and she was found to be in organ failure. Despite the best efforts of the clinicians to treat her, they were unsuccessful, and her life support was withdrawn. Ms K’s death was reported to the coroner and an inquest conducted. 

Medical records – medication error 

On admission Ms K was prescribed a standard adult dose of 1g paracetamol four times daily. This was entered on the handwritten medication chart. However, when the anaesthetist reviewed the chart before surgery, he was concerned the dose was too high given her low body weight.  He cancelled the 1g dose and prescribed 600mg four times a day, which he recorded in the handwritten chart.  After the surgery, only one 600mg dose of IV paracetamol was documented on the handwritten medication chart as having been given.  

When Ms K was transferred to the ward, a junior medical officer transcribed the handwritten medication chart into a digital medication record. The junior doctor did not recall seeing the anaesthetist’s handwritten medication change and entered the original prescription of 1g of paracetamol. There was uncertainty as to whether the transcription of the medication chart occurred before or after the anaesthetist’s handwritten change. Consequently, the error was undetected, and Ms K received 1g of paracetamol on 13 occasions over the next five days. 

The medical evidence at the inquest indicated that 1g four times daily was an excessive dose for Ms K’s weight, exceeding the recommended maximum amount both per individual dose and per day.   

Since Ms K was nil-by-mouth following her surgery, all medications were administered intravenously. It appears no review of her medications occurred in the days following surgery. By the time blood tests were conducted, Ms K’s liver function tests revealed significant abnormality. 

Ms K was admitted to ICU and diagnosed with liver failure, likely due to paracetamol toxicity. Despite treatment, her condition worsened and the treating team determined she could not survive her organ failure. Ms K died with the cause of death recorded as multiple organ failure due to adhesions, related bowel perforation (surgically treated) and paracetamol-induced liver failure.  

The coroner was highly critical of the hospital’s lack of processes or guidelines for paracetamol administration. He found that while guidance tools such as MIMs, AHM and Up-To-Date were available, there was no evidence they had been used. He criticised the hospital for not adopting best practice used by other health authorities such as including paracetamol on the list of high-risk medications, providing guidance on dosing levels and requiring regular reviews. 

While the hospital had implemented alerts in the digital health record to warn and verify doctors of appropriate medication dose ranges, the coroner highlighted that these alerts were still open to human error, such as inputting an incorrect patient weight.   

The coroner recommended the health service publish data on adverse medication outcomes since the introduction of the digital health record system to determine its effectiveness in reducing risk of adverse outcomes. 

This case highlights the tragic errors that can occur when information is being transcribed between handwritten and electronic records. While electronic records can help mitigate the risk of errors, for example through automatic alerts, they do not replace the need to exercise clinical judgement. 

• Extreme care should be taken when transcribing or transferring information between systems or institutions. This can also include discharge summaries and verbal handovers. 
• Ensure there is one source of truth, in this instance removing the written medication chart once transcribed into the EMR. 
• Access available clinical guidelines or other resources to support your clinical decisions.  
• Always be aware of when weight-related dosing is relevant.  
• Consult colleagues for clinical input as needed and follow hospital processes such as regular reviews of medications, to try reduce the risk of error. Each individual involved in administering a medication needs to be satisfied about the dosage, appropriateness and other related issues. 
• Where an unusual dose of a commonly-prescribed medication is ordered (such as a lower maximum paracetamol dose), ensure it is clear to others in the treating team that this is the case. 

Avant factsheet: Prescribing drugs of dependence 

Avant factsheet: Coronial investigations and inquests 

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