On Wednesday night, an urgent memo was sent out to staff at five major South Australian hospitals warning that SA Health’s electronic records system for patients, Sunrise EMR, had been wrongly duplicating numbers in dosage prescriptions.
The memo warned nursing and midwifery to be on “high alert” for unusually high dosage numbers, and asked prescribers to “review all orders in the order entry worksheet prior to submission and correct the dose as required”.
SA Health Chief Executive Chris McGowan this morning said the software had been adding a digit and replicating the last number of each dosage.
“So if you were to have 70 milligrams, you would be prescribed 177 milligrams,” McGowan told ABC radio.
The health executive confirmed that SA Health does not yet know how many incorrect doses were administered, if anyone has been adversely affected or how long the problem was affecting prescriptions.
He said that he is “not aware of any negative outcomes for patients”, but a review has been launched to examine the issue.
The glitch affected the Queen Elizabeth, Royal Adelaide, Noarlunga, Mount Gambier and Port Augusta Hospitals.
Regarding how long it took for the glitch to be picked up, McGowan said: “It would surprise me enormously if it was a long period of time”.
“Nurses know what they’re doing, doctors know what they’re doing … these are very highly qualified pharmacists, so when they start seeing prescriptions for particular drugs of 177 milligrams, my assumption is, they’re very quickly alerted,” he said.
An SA Health memo sent to hospital staff at 2:37am this morning said the “root cause” of the issue is yet to be discovered, but an “interim work around” has been found in the meantime.
“The EMR Project team and Digital Health SA have been working with Microsoft and Allscripts to understand the potential cause of an intermittent issue with repeated keystrokes creating the potential for ordering errors in Sunrise,” the memo reads.
“The root cause of this issue is still to be confirmed, but the current line of investigation is an issue in the Microsoft Remote App.
“The EMR team have been able to replicate the issue and logs have been captured to support Microsoft’s investigation.”
McGowan went on to say later in the day that “we think we have an understanding of what caused it”.
“[The glitch] was a generic issue in the prescribing software – it’s a patch relating to upgrading to Microsoft 10.
“That’s the operating hypothesis at least, but that’s been checked and that will be part of the review.”
Shadow Health Minister Chris Picton called for an independent investigation of the glitch and for a patient hotline to be set up to answer concerns about overdoses.
“It is increasingly worrying that SA Health can’t even identify what is causing this problem,” Picton said.
“It raises bigger questions as to whether there are issues in the architecture of the [computer] system that are causing these problems.
“To have such a 1000 per cent error in such an important element of the system as medication is extremely concerning.
“This is a system which is meant to help reduce medication errors, not exacerbate them.”
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