This appeared last week:
Years go by and deadly chemo blunder fix still a work on paper
Brad Crouch, Health Reporter, The Advertiser
June 7, 2020 9:30pm
SA Health has finally moved to issue a new tender for a fail-safe chemotherapy dosing system as years after recommendations for swift action following the deadly underdosing blunder were handed down.
Underdosing victim Andrew Knox said he was caught in an “endless groundhog day” nightmare of promises to fix the system and noted, even with the latest move, a new system would not be in place until next year.
As revealed by The Advertiser last October, plans for a new backup computer program designed to prevent a repeat of underdosing patients were dumped after a risk assessment found the tender was not up to standard.
It followed the scandal exposed by The Advertiser which showed 10 seriously ill cancer patients were underdosed in the bungle between 2014 and 2015, and four have since died.
Mr Knox said he wasn’t “holding my breath” for a fail-safe system any time soon.
In November 2017, the Select Committee on Chemotherapy Dosing Errors found “The protracted time frame for the implementation of a state wide electronic system for chemotherapy protocols is unacceptable.”
It recommended that a state wide chemotherapy protocol system “be expedited”. Now, seven months after its first tender plan was cancelled, SA Health has announced a new tender will be issued.
However, the preferred supplier is not expected to be appointed until the end of the year, with no time frame on when a new system will actually begin operating.
In a message to staff, deputy chief executive Lynne Cowan said the system SA Health was seeking would: “reduce the risk of adverse events relating to chemotherapy and cancer survival in South Australian hospitals (and) improve medication safety resulting in a reduction in errors and serious untoward events.”
More here:
This is an amazing procurement saga for a not all that hard or complex stand alone computer system which would only be used in a quite limited number of hospitals.
I get that chemo-dosing is important to get right but it is not rocket science by any means and I am sure there are at least three or four quality systems if one looks.
This has been a long saga. This article from 2018 provides background and links to earlier stories on the issue.
New chemotherapy prescribing IT system aims to prevent underdosing and 'risk of errors'
Posted 15 November 2018
The South Australian Government is looking to introduce a computer system that could reduce the risk of human error in prescribing cancer drugs, after a chemotherapy underdosing bungle in two major Adelaide hospitals.
The State Government hopes a state-wide cancer prescribing IT system, which has been advertised for tender, will prevent a repeat of the mistakes made in 2014 and 2015.
Key points:
- Four cancer patients died in Adelaide after being underdosed during chemotherapy treatment
- A report is being prepared into the four patients' deaths after a long-running inquest finished earlier this year
- State Government says an IT system could prevent a repeat of the underdosing bungle
Christopher McRae, 67, Anne Pinxteren, 76, Bronte Ormond Higham, 68, and Carol Bairnsfather, 70, died after they were underdosed during their chemotherapy treatment at the Royal Adelaide Hospital and Flinders Medical Centre.
Over a six-month period, patients at the two hospitals were given one dose of the chemotherapy drug Cytarabine a day, when they should have been given two.
Health Minister Stephen Wade said the Enterprise Chemotherapy Prescribing System was promised by Labor in 2010 but never implemented.
"What we saw through the chemotherapy dosing saga was that a chemotherapy prescribing system would have reduced the risk of errors," Mr Wade said.
"One of the exciting elements of this project is that it will be state-wide.
"So many of our IT systems are not available to our country patients — and the whole point with the cancer-prescribing IT system is that no matter where South Australians go, whether they're travelling or whether they're a resident beyond the metropolitan area, they're entitled to the best cancer care.
Here is the link:
A quick scan of the literature reveals lots of work in the area with lots of electronic medication management systems available.
While a complex area it is more than doable and SA should really stop making such a meal of this and get on with selection and implementation ASAP!
David.
1 comment:
It seems to be a common strategy in government. If there is clear and reliable evidence of a severe problem (e.g. chemo delivery) - ignore it. If there is no evidence of the benefit of a half baked solution (e.g. My Health Record) just keep spending mega-bucks on it and hope a miracle happens.
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