SA Health high alert as Sunrise computer system adds extra digit to medicine dosages

The computer at the heart of SA Health’s patient care has started adding extra digits to medication dosages, turning 10mg into 100mg.

Nurses have been put on high alert to check medicines in hospitals after a computer bungle started adding a digit to medication prescriptions, turning 10mg doses into 100mg doses.

An urgent memo sent out on Wednesday night by SA Health’s Clinical Solution Support Centre warns in some cases the last digit of a prescription order is being replicated.

It says nurses should be on alert to check for “high-dose medication orders”.

The problem is with the electronic patient record system known as Sunrise, which grew out of the troubled EPAS system – which itself was so disastrously late and over budget it was suspended then scrapped.

The memo states that “The EMR Project is aware of an issue that is intermittently impacting medication order dosing in Sunrise EMR.

“This issue can result in the last digit of the medication dose being duplicated prior to order submission, eg 10mg may display as 100mg, 15mg may display as 155mg. It is important for all staff to be aware and carefully review all medication orders.

“Prescribers should review all orders in the order entry worksheet prior to submission and correct the dose as required.

“Nursing and Midwifery staff should be alert to high-dose medication orders and follow-up with prescribers prior to administration.”

Computer experts are now investigating the cause of the issue and will provide staff with updates. They urge staff to alert other staff members who do not have access to email of the situation.

SA Health officials say they are not aware of any adverse patient outcomes.

“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,” a SA Health statement says.

“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.

“We are not aware of any adverse clinical outcomes at this time.”

Hospitals using the Sunrise EMR for clinical use are the Royal Adelaide Hospital, the Queen Elizabeth Hospital, Noarlunga Hospital, Mt Gambier and Districts Health Service and Port Augusta Hospital.

Elizabeth Dabars, the SA head of the Australian Nursing & Midwifery Federation, called for additional staff to help until the problem was fixed.

“It has the absolute potential to be catastrophic,” she told ABC Adelaide.

“Depending on the circumstances and depending on the patient, it could be fatal.

“The staff are already fatigued that they’re working double shifts and overtime.

“That then really escalates the risk, because if people are unfamiliar with the patient and what the usual medications are in the ward.”

Andrew Knox, a victim of the chemotherapy underdosing scandal, called for a new level of reporting of dangerous events in SA Health which would result in immediate action rather than drawn out investigations.

Andrew Knox, one of the ten underdosed chemotherapy patients at his Adelaide Hills home. Picture: Tricia Watkinson

“It is very disturbing to hear this, in my view it is very serious because it is effectively how the underdosing occurred – pharmacists following what they believed to be true with the dosage,” he said.

“For someone like myself who follows their established medication regimen closely, you would not take an unusual dose, but for people under stress or are having new medication for a new problem, they would probably not think to check it themselves.

“You are at the mercy of the system and hopefully there is someone diligent enough to pick up an error.”

Mr Knox noted the Sunrise system has benefits in electronically collating all a patient’s records and “it saves me lugging kilos of records around”.

He also observed repeated tenders to provide a failsafe system for chemotherapy medication separate to Sunrise had still not resulted in a system.

The chemotherapy scandal exposed by The Advertiser revealed 10 seriously ill cancer patients were underdosed in the bungle between 2014 and 2015, and four have since died.

It was caused by a typo that halved their dose.