Medication errors prompt calls for electronic systems

ELECTRONIC systems to prevent medication mistakes seem likely to be implemented in the South in the wake of two serious adverse events.

The move would also be in line with the main finding of a recent Health and Disability Commissioner report in to medication errors.

A Southern District Health Board investigation into a patient being prescribed the wrong amount of medicine recommended medical electronic information systems be integrated, and asked that the Ministry of Health overhaul systems so all alerts regarding medical restrictions were made electronically to all health providers via the National Medical Warning System.

That case was one of two medication mistakes incidents detailed in the SDHB’s annual adverse events report.

Few details were provided, but clinical staff were unaware a medicine restric tion notification was in place for a patient, and the wrong volume of medicine was prescribed.

The report said there needed to be an effective consistent electronic mechanism for alerting health practitioners that a restriction notice may be in place.

It also suggested additional pharmacist support be provided to all patients across the hospital.

The patient later died.

All the investigation’s recommendations were noted as being completed.

In the second SDHB mistake, incorrect medication was administered intravenously, which caused the patient heart trouble.

Interruptions and distractions were a factor, as were the ward being extremely busy and noone independently double checking the medicine.

A series of changes, which included standardised IV medication administration process and audit compliance and compulsory staff education on IV policy.

The recentlyreleased HDC report studied medication related errors nationwide from 200916 — about 300 complaints in total.

While errors were rare, medication was the most common intervention in health care so it was important it was administered correctly, commissioner Anthony Hill said.

‘‘When medication errors do occur they have the potential to cause significant harm.’’

A notable feature of the medication errors reported to the HDC were how many had failure to follow policies and procedures as a contributing factor, Mr Hill said.

That could point to a system that allowed a culture of tolerance to emerge — where the suboptimal became normal, and not following policies and procedures became everyday practice.

Electronic medicine management systems needed to be standard, and could play a major role in prevention of medication errors, Mr Hill said.