This report appeared last week:
SA hospital staff put on alert after computer glitch adds digit to medication dosages
Posted 6 May, 2021 at 9:51pm
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.
Key
points:
- Staff at some SA hospitals received a memo about a computer system error
- The glitch was duplicating the last digit of medication doses
- SA Health says it's not aware of any "adverse clinical outcomes"
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.
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."
More here:
https://www.abc.net.au/news/2021-05-06/sa-sunrise-dosing-error-hospitals-dosing-glitch/100122642
There is local coverage here:
SA Health unable to find cause of computer system error adding extra digit to medicine dosages
Tech experts are unable to find why SA Health’s computer system at the major hospitals is creating dangerously high medicine doses.
May 7, 2021 - 12:34PM
Computer experts are stumped by why the Sunrise computer at the heart of patient care in major hospitals has started adding an extra digit to medicine prescriptions.
The glitch means 10mg doses are being turned into 100mg, 15mg into 155mg and so on.
Frantic around-the-clock efforts to fix the problem so far have failed, resulting in an urgent memo sent at 2.37am on Friday warning “the root cause of this issue is still to be confirmed.”
As revealed exclusively on advertiser.com.au, the Sunrise computer system is intermittently replicating the last digit in some prescriptions.
Nurses have been put on high alert to double check the dosage being given to patients is what the doctor ordered, rather than what the computer generated.
An urgent memo sent out on Wednesday night by SA Health’s Clinical Solution Support Centre says nurses should be on alert to check for “high-dose medication orders”.
Officials have not revealed how long the problem has been going on and say at this stage they are unaware of any adverse patient outcomes.
Friday’s memo says SA Health’s digital team has been working with Microsoft and system provider Allscripts to try to find the cause and are checking various possibilities.
With no paper records now in use, hospital staff are being advised to use a remote desktop application “as an interim work around” to try to avoid the problem.
The Sunrise electronic patient record system is in use in the Royal Adelaide Hospital, Queen Elizabeth Hospital, Noarlunga Hospital, Mt Gambier and Districts Health Service and Port Augusta Hospital.
More here:
I find the second article rather odd in that it is suggested that the source of the error can’t be traced but there is no mention of checking updates and changes to the system in the recent past. Computers don’t just suddenly begin ‘behaving badly’ without some reason – someone has changed something.
Anyway it should be possible to trace the error very simply.
More worrying is that does not appear to be a replacement manual system that can be used while the problem is traced and fixed. Surely with this sort of error you stop using the system until you know what is going on?
All in all the error(s) is a bad thing but the response seems to be rather slack and overly relaxed!
What do you think? Anyone have any credible explanations of what is going on?
David.
3 comments:
Amazing and concerning, not just that it has happened, but they can't fix it
"Computers don’t just suddenly begin ‘behaving badly’ without some reason – someone has changed something." Or a sticky keyboard? If they haven't checked that, they should have.
I find this particularly odd. "The memo states that 10mg may display as 100mg and 15mg could display as 155mg."
Surely the medicines datafiles are standard across all AllScripts installations. Surely the doctor doesn't type in the script eg. "Amoxicillin caps 250 mgm 8 hourly x 7 days". Surely the doctor selects the medicine and appropriate dosage from a "DROP MENU". If so this makes it almost impossible to add an extra digit to the required dosage.
I hope someone will reassure me.
Mmm ... That's a good point. The system we use allows us to click and pick. It's only very occasionally that we have override and manually 'edit' the dose presented on the screen. So I agree there must be another reason for the extra repeat digit appearing on the dose. Could the system be infected with a virus which cuts in at random?
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