Earlier this month, a man in a New Zealand hospital died due to opioid toxicity after he was administered what turned out to be a fatal dose of fentanyl. According to a local news report covering the story, the error was a result of system-wide failures across the spectrum of care providers.
The victim of the error was at the hospital for a routine knee surgery. The hospital had just implemented a new e-prescribing system the month before, whereby physicians could order medication at a patient’s bedside with one touch on a computer screen. The physician overseeing the victim’s care was attending to another patient when he remembered to put in an order for the victim’s medication. The physician input the medication order and then returned his attention to the other patient.
The physician, however, failed to switch the computer screen back to the patient who was with him. Thus, when the physician entered a medication order for fentanyl patches that was intended for the other patient, the order was sent to the victim’s file.