Friday, November 07, 2014

Not Something To Boost Confidence In Hospital Software. Need Clarity That Full Fix Has Been Delivered!

This story started running around the middle of last week.

Health software brings risk of death

Date October 27, 2014 - 7:12AM

Tony Moore

A new software program installed to manage medication doses at nine Queensland hospitals is likely to kill a patient within the next month, a Queensland Health risk report says.
Last Friday's report on the Metavision Intensive Care program advised the state government that the likelihood of the program causing preventable loss of life "is assessed as likely and expected to occur within the next month".
Health Minister Lawrence Springborg confirmed the report, which described the likelihood of a patient death at 60-90 per cent, to Fairfax Media on Sunday.
Concerns over the software were identified in the past month by the directors of the Intensive Care Units at the Princess Alexandra, Royal Children's and Royal Brisbane and Women's Hospital.
The software, designed to regulate the doses of medicine given to patients, was first introduced in 2013 and implemented at the Royal Brisbane and Women's Hospital as recently as September this year.
"Since implementation, monitoring of patient records by pharmacists has revealed several potentially serious prescription errors specifically caused by the system," the report says.
"While no events have resulted in actual patient harm, they are considered to be near misses with a high potential to recur."
The system was manually over-ridden by Queensland Health on Friday, and medical charts are being reviewed daily by intensive care unit medical teams.
Lawrence Springborg agreed a serious problem had been identified.
Lots more here:
There was also coverage here:

Dosage software deemed 'deadly'

27 October, 2014
A new computer program that helps manage patients' medication at nine Queensland hospitals could prove deadly, a Queensland Health report says.
The risk report says the Metavision Intensive Care program could cause preventable loss of life within the next month, Fairfax Media reports.
The software is designed to regulate doses of medication given to patients but drugs have allegedly been mixed up or continued when they should have stopped.
It was manually overridden by Queensland Health on Friday after the report was published.
Health Minister Lawrence Springborg has confirmed the risk report, which put the likelihood of a patient death at 60 to 90%.
More here:
A more detailed article appeared later in the week:

Doctors say critical Queensland Health software bug treatable

A software glitch that hit the system used to dispense medications to hospital patients in Brisbane’s public Metro North Hospital and Health Service has again put Queensland Health’s technology performance in casualty after the state’s Nurse’ union and Labor Opposition hit out at life threatening dangers revealed in an internal risk report.
The computer bugs affected software supplied by iMDsoft for Metro North’s Metavision Intensive Care system and came to light after risk assessment provided to the state government warned there was a 60 per cent to 90 per cent chance of preventable death occurring over the period of a month if left unaddressed.
The serious near miss and subsequent manual intervention has put health services across Australia on alert over how potential problems and associated risks of eHealth systems are managed as most states pursue the big technology rollouts.
The issue of the Metavision implementation hit Queensland’s state Parliament on Tuesday with the Labor Opposition launching into the Newman government over what was being done to tell patients about the risks of the IT system being used to prescribe medication to them.
Predictably, the flurry of questions prompted a succession of reminders of the Bligh government’s now globally infamous software disaster of the Queensland Health Payroll that chewed through $1 billion was slammed in a subsequent Royal Commission and resulted in IBM being banned from government work in the state.
Politics aside, doctors and the software company at the centre of the controversy say the very fact that the problems were detected is in itself a salutary lesson about how risks surrounding such problems can and should be managed.
Lots more here:
What seems to be good here is that an error has been identified, a workaround developed and a permanent fix to the software has been developed.
It is worth visiting the company web-site which is found here:
The company certainly has an impressive client list and I strongly suspect the Company has far too much to lose to not swiftly rectify whatever the core issue is.
This rather has the sense of a bit of a ‘storm in a teacup’ while at the same time clearly needing to be fully understood and fixed!
David.

5 comments:

Anonymous said...

Software inherantly has bugs and humans make errors, the positive here is the checks and balances seemed to work.

I have a bigger question, I have noticed again the PCEHR is not avaliable for essential maintenance, this has been the case several times in the last six weeks, with consumers and providers being advised they cannot use the service. How is it a national health records system can be offline for extended periods of time? Especially over a weekend when I would assume more people are outside there immediate local area and health record access might be the difference between life and some more serious? That is the purpose after all.

InformaticsMD said...

See my comments on the Metavision affair at Healthcare Renewal, http://hcrenewal.blogspot.com/2014/11/bug-in-metavision-icu-system.html

- Scot Silverstein

Anonymous said...

InformaticMD, very nice summary, my concern will be governments answer will be to transfer risk by pushing for software companies to self regulatie through some sort do it yourself certification program.

Anonymous said...

"How is it a national health records system can be offline for extended periods of time?"

Because it's a Mickey Mouse system, not designed for purpose. It's unsafe, unreliable, unnecessary and should be treated as untrustworthy and with suspicion by all who go near it.

Apart from that, it's OK.

Anonymous said...

With goofy in charge of requirements, daffy running design and donald duck flapping in integration support, its only fitting you end up with a micky mouse system.