Middlemore Hospital investigates machine fault before patient later died

Middlemore Hospital. Photo / File

By Stephen Forbes, Local Democracy Reporter

Investigations are under way into a faulty machine that jammed during an attempted resuscitation of a patient who later died at Middlemore Hospital's emergency department.

The event was outlined in a Counties Manukau District Health Board (DHB) report, which said a mechanical fault with an automated dispensing machine, or Pyxis machine, caused a delay in accessing vital medicine.

"The DHB is not entirely sure the machine fault is related to the death, but a full investigation is under way."

According to the report, the patient had a cardiac arrest before coming into the hospital.

Staff in the emergency department couldn't immediately access the necessary medication from the machine, which had become jammed.

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

The machines record each transaction so staff don't need to manually count doses and notify a hospital's pharmacy when supplies run low.

In the report, Counties Manukau Health chief medical officer Dr Peter Watson said an external review is under way to determine what part the machine fault played in the death.

An expert is expected to advise the DHB of their findings.

Watson said once the review is concluded, an alert would be sent out to other hospitals if appropriate.

"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."

Watson said the manufacturer hadn't yet been contacted.

"For now, the DHB is working to ensure they understand what the issue was in a very short period of time."

In a statement, Watson said cardiopulmonary resuscitation (CPR) was conducted in the ambulance en route to the Emergency Department (ED) at Middlemore Hospital.

"The patient required ongoing CPR due to multiple episodes of full cardiac arrest for over 45 minutes prior to arrival at hospital," he said.

"The patient was receiving full CPR on arrival at hospital and the resuscitation efforts were continued in the ED, for approximately one hour.

"The patient was critically unwell and was transferred to the ICU where they passed away following further cardiac deterioration."

Watson said the issue with the machine hadn't previously been identified by staff as the medication was not typically used during resuscitation.

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

Watson said an internal review found the machine's malfunction was "highly unlikely to have altered the outcome as the patient was already critically unwell on arrival".

The external review is expected to be completed soon.

Counties Manukau Health will notify the manufacturer of the findings of both the internal and external reviews.