Australia SA hospital staff put on alert after computer glitch adds digit to medication dosages

16:17  06 may  2021
16:17  06 may  2021 Source:   abc.net.au

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SA Health is investigating whether patients have been overdosed with medication as a result of a glitch in the computer system used at some of the state's major hospitals.

On Wednesday night, staff at the Queen Elizabeth Hospital, Royal Adelaide Hospital and Noarlunga Hospital were sent an urgent memo informing them of an issue with the Sunrise computer system which was duplicating the last digit of medication doses.

The memo states that 10mg may display as 100mg and 15mg could display as 155mg.

It calls for nursing and midwifery staff to be "alert to high dose medication orders" and follow up with prescribers prior to administration.

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The Sunrise system is also used at the Mount Gambier and Districts Health Service and at Port Augusta Hospital.

In a statement, a spokesperson for SA Health said they were not aware of any "adverse clinical outcomes" at this time.

"As soon as we became aware of the intermittent issue, all sites using the Sunrise system were notified and implemented risk mitigation strategies or business continuity plans," they said.

"Additional prescription reviews by medical officers, nursing, midwifery and pharmacists are in place while we investigate the root cause of the intermittent issue."

"As well as this, an additional alert has been added to the medication ordering screen."

Andrew Knox, a victim of SA Health's chemotherapy bungle, said he was disturbed that such a dangerous error could happen again.

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"I found it particularly disturbing because the parallel to our underdosing and the failure on this occasion is quite close," he said.

"I think that the main concern is that I doubt the system is there to cope with it.

"Merely sending out an urgent memo to nursing staff to be on the lookout for what appears to be higher dosages is simply no better than what we experienced and what the deputy coroner deplored."

Mr Knox was one of 10 cancer patients who were incorrectly given one instead of two daily doses of a chemotherapy drug over a six-month period in 2014 and 2015.

"In our case, a not-so-urgent memo went out to 40 clinicians and the evidence was that nobody read it," Mr Knox said.

Mr Knox said failsafe mechanisms needed to be put in place.

"It's not sufficient for technicians or IT people to say, 'Oh well, we are looking for the glitch'. There has to be a failsafe mechanism that swings into action as soon as something like this happens," he said.

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usr: 1
This is interesting!