This appeared last week:
Software glitch changing doses on GP scripts for RHD drug
The issue could result in potential under-dosing in patients with acute rheumatic fever and rheumatic heart disease
25th November 2020
By Kemal Atlay
A glitch in Best Practice software means the wrong dosages have been printed when doctors issue repeat scripts for a rheumatic heart disease (RHD) treatment.
SA Health has urged all GPs who manage patients with acute rheumatic fever or RHD to be aware of the issue when prescribing Bicillin LA injections, warning it could result in significant under-dosing.
The issue emerged after Pfizer changed the unit measurements for the long-acting penicillin from 900mg/2.3mL to 1,200,000 units/2.3mL in early 2019.
At the beginning of this year, a GP in South Australia reprinted an old script for Bicillin from a patient’s past prescription list.
According to SA Health, the software updated the drug’s strength to the new unit measurement, but the dosage was subsequently halved to 600,000 units/1.17mL (the dose for a child under 20kg) when the script was printed.
The doctor did not check the reprinted script and the patient was dispensed half of the intended dose, which was administered every 21 to 28 days over a 10-month period.
When another repeat was reprinted in October this year, the same error occurred, but this time it was picked up by a nurse, who alerted the GP.
Best Practice, which stressed new scripts for Bicillin are not affected, said it has now corrected the Bicillin LA dosing measurements listed in its database.
More here:
https://www.ausdoc.com.au/news/software-glitch-changing-doses-gp-scripts-rhd-drug
Yet another story where a train of events, each of themselves innocuous, have joined / conspired to result in an error that could have real consequences for a patient.
One can only thank the eagle-eyed nurse for spotting the problem and leading to it being fixed!
There really some errors is it virtually impossible to catch up front I believe and the warning is clear -check and verify as often as you can! Human alertness is the final defence!
David.
1 comment:
The change to My Health Record to make it opt-out rather than opt-in is a classic Nudge tactic.
Unfortunately, Nudge tactics only work when the action being promoted is obviously of benefit, but many people just don't get round to it. MyHR does not fall into that category - it's still useless, even if people are registered. Fail one for Nudge.
The Department of Health has just been rapped over the knuckles for another Nudge failure.
Audit office fails Dept of Health on nudge letters
https://medicalrepublic.com.au/audit-office-fails-dept-of-health-on-nudge-letters/38066
The Department of Health seems to have a record of being taken in by snake oil sales(wo)men.
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