A week of so ago there was a report of so called ‘unexplained’ errors in the doses of medication being prescribed at a number of SA Health hospitals.
Here is a link to the blog:
https://aushealthit.blogspot.com/2021/05/this-sounds-all-very-strange-to-me-i.html
We now have an update:
Doctors told patients may have had 10 times intended drug dose
SA Health CEO Chris McGowan says a review is underway into a software glitch that added an extra digit on hospital scripts
10th May 2021
Doctors at several large public hospitals have been warned that their patients may have received 10 times their medication dose in error after a software upgrade caused a “serious” computer glitch.
An urgent memo was sent to clinicians at at least three SA hospitals on Wednesday night, warning them of problems with the Sunrise electronic medical records system, according to a statement from the Nursing and Midwifery Federation.
The “serious” issues added an extra digit to prescription orders, and had the potential to impact patient safety, the federation said.
The memo was sent to staff at hospitals including the Royal Adelaide Hospital, Queen Elizabeth Hospital and the Noarlunga Hospital.
“This issue can result in the last digit of the medication dose being duplicated prior to order submission, for example, 10mg may display as 100mg, 15mg may display as 155mg,” the memo said.
SA Health CEO Chris McGowan said the situation was being reviewed, and it wasn’t yet known many patients had received incorrect doses, or how long the problem existed before coming to light.
"It was a generic issue in the prescribing software. It's a patch relating to upgrading to Microsoft 10.” Mr McGowan told ABC News.
“That's the operating hypothesis at least, but that's being checked and that'll all be part of the review.
More here:
https://www.ausdoc.com.au/news/doctors-told-patients-may-have-had-10-times-intended-drug-dose
So it seems one of those pesky updates bought along some mischief. No the hand of God but of Microsoft Update! A much more common source of problems all over the globe!
I think this can now be safely put in the ‘explained’ column!
David.
1 comment:
David, re "It was a generic issue in the prescribing software. It's a patch relating to upgrading to Microsoft 10.” Mr McGowan told ABC News.
This statement is open to interpretation.
It does not say that the patch is a Microsoft patch, it could well be (and IMHO is probably) a patch from the prescribing system vendor to cope with Windows 10 (not Microsoft 10).
And it's still a guess so I wouldn't take it out of the unexplained column just yet.
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