A new software program installed to manage medication doses at nine Queensland hospitals is likely to kill a patient within the next month, a Queensland Health risk report says.
Last Friday’s report on the Metavision Intensive Care program advised the state government that the likelihood of the program causing preventable loss of life “is assessed as likely and expected to occur within the next month”.
Health Minister Lawrence Springborg confirmed the report, which described the likelihood of a patient death at 60-90 per cent, to Fairfax Media on Sunday.
Concerns over the software were identified in the past month by the directors of the Intensive Care Units at the Princess Alexandra, Royal Children’s and Royal Brisbane and Women’s Hospital.
The software, designed to regulate the doses of medicine given to patients, was first introduced in 2013 and implemented at the Royal Brisbane and Women’s Hospital as recently as September this year.
“Since implementation, monitoring of patient records by pharmacists has revealed several potentially serious prescription errors specifically caused by the system,” the report says.
“While no events have resulted in actual patient harm, they are considered to be near misses with a high potential to recur.”
The system was manually over-ridden by Queensland Health on Friday, and medical charts are being reviewed daily by intensive care unit medical teams.
Lawrence Springborg agreed a serious problem had been identified.
The software’s manufacturer has been asked this week to urgently provide a software “patch” to address the problems.
“But the important thing is that because it was identified they have been able to identify and to manage any risks,” Mr Springborg said.
“Because it has been manually identified, they have been able to work out what the risks are and what to look for.”
Testing begins this week, Dr Chris Joyce, Chair of the Intensive Care Clinical Information Board told Fairfax.
“The project’s steering committee was aware of the issue and arranged to have a system upgrade provided by the ICT company to fix the problem,” Dr Joyce said,
“This is to be tested next week and rolled out the week after if the testing is successful,” he said.
Mr Springborg said there were 1.8 million people treated in Queensland hospitals every year and around 4.5 million people who came in as outpatients.
He said ‘mis-medications’ were a constant problem.
“I am very, very confident that because our clinicians have identified this, they know where the risks are, we will be able to manage it.”
The software is used at mroe than 100 hospitals worldwide, Mr Springborg said.
Opposition health spokeswoman Jo-Ann Miller said the situation was “extremely serious” and immediately called for an independent assessment from outside Queensland Health.
“It is clear that there has been a number of cases where patients safety has been put at risk, where medications may have been mixed up, where medications have continued to be administered when they should have stopped, and where medications should have been administered but were somehow removed from the system,” Ms Miller said.
She said the report showed patient safety was compromised.
“It is clear that there are bugs in this system that could result in catastrophic results for the patient,” she said.
“There are also potential breaches of the legislation that protects the patients, doctors and nurses who are responsible for the treatment.
“The sickest of the sick are in intensive care units across Queensland and this system’s risk rating is ‘Very High’.
Ms Miller said an immediate independent investigation was necessary.
“I am calling for the Minister for Health to order an immediate independent review of this system, outside of Queensland Health and the Hospital and Health Boards, and that systems be put in place to protect patient safety.”
Queensland Nurses Union state secretary Beth Mohle said she was horrified when told of the problem.
Ms Mohle said the unit that had identified the problem – CARU, the Clinical Access and Re-design Unit – was “off to one side” and did not have regular contact with the Chief Nurses’ office.
“These things just get designed off to one side, and just lumped on people to implement without any resource implications about whether it is actually doable,” she said.
She said she was very worried that the reduction in nursing numbers raised serious questions about whetherr there were enough nurses to manually check changes to prescriptions.
“I have not heard specifically about this, but nurses are very concerned about systems that are being put in that are – if you like – alleged risk systems – that are an onerous burden on practioners.
“And it is over-riding clinical judgment to a large extent.”
“There is a problem in there in terms of the right hand not knowing what the left hand is doing in the system as well.”
Source: Brisbane Times