Medical Data Mix-up, Major System Error Down Under - But Nobody Harmed, Of Course

This from Down Under. Apparently an American IT system by Cerner was involved:

Medical data mix-up, major system error

Kate Hagan | August 5, 2011

MELBOURNE hospitals have sent incorrect patient records to GPs due to an error with Victoria's troubled health technology program over the past two months.

The discharge summaries from Eastern Health and the Royal Victorian Eye and Ear Hospital mixed patients' names with other patient data, including test results and diagnoses.

[A major patient misidentification error - ed.]

The data was faxed to GPs under the HealthSMART program, which Health Minister David Davis has described as ''the myki of health''.

[I think 'myki' refers to the contactless smartcard ticketing system being introduced on public transport in Victoria, Australia. Did I mention I despise comparisons of healthcare to public transit, having started my career in the latter industry? - ed.]

Mr Davis yesterday said: ''This latest error raises further concerns about [former health minister] Daniel Andrews's judgment when designing the HealthSMART system.''

The Health Department was alerted to the record mix-up last month after two GP clinics raised the alarm.

Department spokesman Graeme Walker yesterday confirmed the bungle and said an investigation found that 13 incorrect discharge summaries were sent out over a seven-week period.

''There was an intermittent error in terms of the sending of discharge summaries in a small number of cases to GPs,'' he said. ''It was the link up between the software and the fax which caused some incorrect collating of material attached to the discharge summaries.''

Mr Walker said no patients suffered as a result of the bungle, which had since been fixed.

AMA Victoria president Harry Hemley said the mix-ups were a major concern. ''When patients are admitted to hospital often their medication is changed and they are given a diagnosis,'' he said. ''Discharge summaries influence our ongoing treatment of the patient. If our [incorrect understanding] is that a patient is on a certain medication, that could have serious implications.''

[Well, yes. How about - injury and death? - ed.]

Mr Davis said yesterday he had been advised of a software fault that led to some patient discharge summaries being distributed to the wrong GP clinics.

''I have sought and received assurances that patient safety has not been compromised,'' he said.

[Patients are NEVER harmed by IT foulups thanks to the Lords of Kobol overseeing the universe of Cybernetica - or something like that - ed.]

Mr Davis told The Age in January that he was considering abandoning the HealthSMART program, which is five years late and has cost the state $405 million, including an $80 million cost overrun.

[He should see what the UK just did with their NPfIT here - they pulled the plug - ed.]

The program, introduced by the former Labor government in 2003, is supposed to link computer systems in hospitals and give doctors immediate access to patient records. But clinical applications are only partially running in four hospitals and doctors say they are costly, outdated and difficult to use.

[That is, they present a mission hostile user experience - ed.]

Victoria's Ombudsman and Auditor-General are currently examining a string of failed information technology projects in Victoria, including HealthSMART, which have run over budget and fall short of their goals despite repeated warnings by the watchdogs.

[Repeated warnings by watchdogs ignored - that is quite familiar to me since my writings on these issues began - in 1999 - ed.]

Dr Hemley said the government needed to take urgent action to implement a system that allowed doctors ready access to patient records, test results and medication details. ''We're sick of hearing how bad [HealthSMART] has been, we're waiting for the Ombudsman to come out with that report so we can get on with this IT business and start it happening so that we can communicate with each other,'' he said.

[I wish them luck. Einstein on insanity: doing the same thing over and over again and expecting different results. - ed.]

''We've got to look at where mistakes have been made, eradicate them and move forward.''

[Yes, it's that simple. Of course, achieving nuclear fission on your kitchen table is easy as long as you have the right components and a pamphlet by Dr. Alfred E. Neuman on the topic - ed.]

Asked whether affected patients had been notified of the error, the Health Department's Mr Walker said that would be done ''at the discretion of either the hospital or GP involved''.

The Eye and Ear Hospital did not return calls from The Age yesterday and Eastern Health referred inquiries to the Health Department.

-- SS