Health boss unsure how many patients impacted by dosage bungle blamed on Windows upgrade
The computer problem resulted in patients potentially receiving dosages more than 10 times the necessary amount. (Unsplash: Marcelo Leal)
South Australia's health chief has said it remains unclear how many hospital patients received incorrect dosages of medication as a result of a computer system error, and has blamed the bungle on a Windows upgrade.
On Wednesday night, staff at several major public hospitals were sent an urgent memo informing them of an issue with the Sunrise EMR computer system.
The system was duplicating the last digit of dosage quantities, with patients potentially receiving more than 10 times the necessary amount of medication.
"It's added another digit and replicated the last digit, so if you were to have 17 milligrams, it would have prescribed 177 milligrams," SA Health CEO Chris McGowan told ABC Radio Adelaide's David Bevan.
"We're doing a full review of course, and I'm not aware of any negative outcomes for any patients but that will be examined over the coming days and that will be made public."
Mr McGowan said impacted facilities included the Royal Adelaide, Queen Elizabeth and Noarlunga hospitals, the Flinders Medical Centre, and hospitals in Whyalla and Mount Gambier.
SA Health chief executive Chris McGowan is unsure how many incorrect doses were administered. (ABC News: Lincoln Rothall)
It remains unclear how many patients received medication overdoses and how many incorrect dosages were administered.
Asked how long the problem went unnoticed, Mr McGowan said that was also unknown.
"We're not sure of that … clearly that's part of the review,"he said.
"It 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 being checked and that'll all be part of the review.
"The continuing roll-out of Sunrise has been incredibly successful but from time to time … there are faults."
Mr McGowan said the issue has now been "rectified" and that it would surprise him "enormously" if the problem was in effect for "a long period of time".
The state opposition is calling for a "full independent investigation" into the error, which health spokesman Chris Picton said potentially put "patient lives at risk".
The Royal Adelaide Hospital is one of at least six sites impacted by the problem. (ABC News: Michael Clements)
The memo sent on Wednesday night urged "all staff to be aware and carefully review all medication orders".
Australian Nursing and Midwifery Federation state secretary Elizabeth Dabars said the extra steps would require extra staff, because it was not necessarily up to nurses to "double check or triple check" every dose as part of their daily routines.
"People do check, but also people do have every right to trust their system," she said.
"If they are really expected to inspect every dose — to double check or triple check, either with their own medical manual, their own pharmaceutical manual, or the doctor — this has significant implications.
"There are instances where a 10mg dose, if it were adjusted to 100mg, would still be considered within range and wouldn't necessarily cause alarm bells to ring."
Associate Professor Dabars said additional nurses were needed to help cope with the implications of the computer glitch and she was concerned about the "absolute pressure and risk that is already in the system".
Loading...But Andrew Knox — a victim of a previous SA Health bungle resulting in the underdosing of chemotherapy patients — took objection to suggestions that workloads were to blame for the fault.
"Elizabeth completely misses the point. It is about these safeguards, it's not just about workload because my underdosing wasn't picked up, in similar circumstances, and that's where the disturbing similarity comes in," he told ABC Radio Adelaide.
"It's not about workload, it's about how this is handled, and someone potentially could die. Nurses are not clinicians."
That prompted an apology from Associate Professor Dabars, who said she accepted what Mr Knox's point "about the safety and systems structures".
"I sincerely apologise. My reference to workforce or workload, I accept, is a bit of an inadequate way of describing what I see as part of system failures," she said.
The Sunrise EMR was flagged as needing "significant improvement to meet clinician expectations" during a review by senior clinical and health management experts in SA in 2018.
Sunrise EMR is a core component of the electronic system which was known as EPAS before its rebranding.