A patient with an aortic aneurysm was supposed to see a specialist but ended up waiting significantly longer and passed away before surgery could take place. According to the investigation, the death may have been influenced by the switch to a new records system.

The aneurysm was discovered during a CT scan in Region Dalarna, and a specialist was contacted, a process that took two weeks longer than planned.

When the woman finally met with the specialist, surgery was planned for the following week. However, the operation never took place as the patient died before it could happen. The region has now filed a Lex Maria report with the Health and Social Care Inspectorate, Ivo.

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“The investigation shows that vague routines for urgent visits and shortcomings in documentation led to the patient not being scheduled in time. The incident occurred during a period of unusually high workload associated with the change to a new records system,” says Robert Blomgren, chief medical officer in Region Dalarna.

The assessment is that the incident was partly caused by Region Dalarna switching healthcare information systems in October last year, which “caused greater challenges than anticipated for healthcare staff.”

Healthcare staff had warned

According to Sveriges Radio, this case is the first known serious incident resulting in death among the nine regions that jointly procured the records system Cosmic. Previously, healthcare staff have also warned that faults in the system could lead to fatalities.

To reduce the risk of similar incidents, several measures have been taken – the procedures for handling referrals have been clarified and it has been specified how information should be communicated between relevant departments. Administrative staffing has also been increased to better deal with the workload.

Widespread dissatisfaction

Earlier in April, a survey among members of the Dalarna Medical Association showed that a full 94 percent have experienced patient safety risks associated with the system.

“If anything, it was even more alarming than expected. Certainly, it’s likely the most dissatisfied who responded, but the fact that more than 400 doctors in Dalarna feel that patient safety has been threatened because of Cosmic is still very serious,” says Erik Frösell, vice chairman of the Dalarna Medical Association, to Läkartidningen.

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