Problems with Queensland’s MetaVision health software system were first reported 17 months ago, in May 2013, and reported in a departmental brief to the executive director of the Royal Brisbane and Women’s Hospital in July 2013.
However, it was not until further “outstanding risks” were identified on October 23, 2014, that they were leaked to Fairfax Media on October 24.
They were confirmed by Health Minister Lawrence Springborg on Sunday, October 26.
However, the 18-month timeline of serious errors – where patients ran the risk of wrong medicines, wrong doses and medicines being given to wrong patients – was not revealed.
Opposition health spokeswoman Jo-Ann Miller said these serious concerns should have been made public.
“These issues should never be covered up because they are about patient safety,” Ms Miller said.
“They should be out in the open for all to see and the Minister needs to take full responsibility.”
Ms Miller said “alarm bells” should have been ringing when these concerns were first raised in 2013, despite the system being used in 100 hospitals worldwide.
“Obviously reports were put into the Queensland Health system,” she said.
“The minister needs to advise the patients and the hospital staff why nothing happened following the initial report in June 2013.”
Ms Miller on Monday night repeated her call for an urgent independent inquiry.
“The needs to be an urgent, independent review into all of the briefings, all the documentation that occurred from when the obvious bugs in the system were first understood by the users of the system.”
On Monday night, the Director General of Queensland Health, Ian Maynard, initiated a review of the governance of the way the MetaVision software was being installed.
“A senior Queensland Health executive will facilitate an urgent meeting of leading intensive care clinicians, pharmacists and iMDsoft this week,” Dr Maynard said.
“The Royal Brisbane and Women’s Hospital is implementing a number of additional controls to safeguard patient safety.”
The original contract with iMDsoft was signed in 2007 and the system was put in six large hospitals from September 2011.
It is costing $2.3 million to include the Metavision at the Royal Children’s Hospital, the Royal Brisbane and Women’s Hospital and the Princess Alexandra Hospital. After concerns were identified in June 2013, a software upgrade was delivered on September 3 and is currently being tested.
Professor Darren Walters, Acting Executive Director of the Royal Brisbane and Women’s Hospital, said safeguards for issues raised last year were already in place prior to the software’s installation at Royal Brisbane and Women’s Hospital in September 2014.
“Immediate action was taken when an additional issue with the medication module was raised on Friday 24, October 2014,” he said.
“Information has been shared with other hospital and health services and additional safeguards have been put in place to ensure patient safety until the system is upgraded. We are linking with the statewide ICU group and will follow all recommended risk mitigation strategies.”
The MetaVision software is run by the German iMDsoft company, which has its head office in Australia in small premises in Federal Street off Musgrave Road at Red Hill.
“Outstanding risks” were first identified by intensive care units at the Royal Children’s, Princess Alexandra and Royal Brisbane and Women’s hospitals in May 2013.
The same month these risks were escalated to iMDsoft and to a group of health units within Queensland’s hospitals that had begun installing the software.
Those health units also included the Safe Medication Practice at the Royal Brisbane and Women’s Hospital, pharmacy units at the Royal Brisbane and Women’s, Princess Alexandra and Royal Children hospitals in May 2013 and the information technology unit at the Royal Brisbane and Women’s hospital.
An iMDsoft spokesman at Red Hill – who refused to be identified – also would not answer questions from Fairfax Media on Monday.
“We are working with Queensland Health to resolve the issues and that is all I have to say,” the iMDsoft manager said.
The report shows the risks in May 2013 were:
– Wrong doses being given to patients;
– Wrong medications for the wrong patient;
– Discontinued prescriptions remaining on nurses work lists; and
– Loss of patient history.
The company’s website shows a history of the implementation of the MetaVision patient management software in nine Queensland hospitals over the past 12 months.
AMA Queensland president Dr Shaun Rudd, a Hervey Bay GP, who became AMAQ president in June 2014, said no concerns had been raised directly with him.
When told concerns had been raised by intensive care units in May and June 2013, he said: “Well, that’s a long time ago.”
When told the specific problems identified in May 2013, Dr Rudd said: “That doesn’t sound good.”
Dr Rudd said he was encouraged the latest problems were identified.
The concerns were only made public after they were leaked to Fairfax Media and verified.
An online health magazine, Pulse, in September 2013 reported the Royal Brisbane and Women’s, Princess Alexandra and Royal Children’s hospitals will join Gold Coast, Prince Charles, Townsville, Rockhampton, Cairns and Logan hospitals.
In September 2013, the iMDsoft system was championed by Brent Richards, director of intensive care at the Gold Coast Hospital.
Dr Richards was chairman of Queensland’s Statewide Intensive Care Clinical Network.
That article says the state government would find money for the remaining hospitals, including Ipswich, Redcliffe, Nambour and Toowoomba.
Premier Campbell Newman – in the absence of Health Minister Lawrence Springborg – defended the lack of testing before the new system was installed, an issue also identified in the report.
“I think it was fair to assume it had been through all the rigor because it had been used for some time,” Mr Newman said.
“But I say to you the reassuring thing is Queensland Health detected the issue, the clinical people in Queensland Health detected this, they’ve moved to ensure that patients here in Queensland but obviously internationally are also being protected by making this known.
“People should take great comfort that the times have changed in Queensland Health, the culture of secrecy and cover-up is over.”
The concerns were only made public after being leaked to Fairfax Media.
Source: Brisbane Times