Computer prescribing error turns 'uneventful' procedure fatal

An anaesthetist accidentally used the wrong patient file

A father of two died in hospital following a routine knee reconstruction because his anaesthetist accidentally entered fentanyl into the wrong computer file, the NSW Coroner’s Court has found.

Paul Lau, 54, died from multiple drug toxicity after being mistakenly prescribed fentanyl intended for another more complex surgical patient at Sydney’s Macquarie University Hospital in June 2015.

The most likely explanation for the prescribing error was that the anaesthetist, Dr Orison Kim, left Mr Lau’s file open on a computer and then returned to theatre, the inquest heard.

He’d been using the hospital’s new electronic prescribing system, TrakCare, and came back to the computer at a later time to enter medication for another patient. However, he accidentally prescribed a fentanyl patch and patient-controlled analgesia for Mr Lau, whose file was still open.

Mr Lau had already been prescribed oxycodone