– We are concerned that the mistake could result in incorrect medication which could be serious, said director of health Bjørn Guldvog in a press release when the error was discovered on June 13.
Just over three weeks later, the Directorate of Health praised all the businesses and practitioners who had contributed to the elimination of e-prescriptions with errors, and said they were almost there. But four months later, there are still active prescriptions with the serious error in the system.
– There are approximately 37 remaining prescriptions in the Preseptformidleren, writes specialist director Jacob Holter Grundt in the Directorate of Health (Hdir) in an email to NTB.
According to Hdir, the vast majority of patient record systems have continued the incorrect dosage when the error has first occurred. The error propagated itself into solutions that handle medication in hospitals, nursing homes and municipal health and care services. Errors have also spread to a multi-dose pharmacy, but there the error has been manually caught and corrected before dispensing.
More challenges
Getting the error rectified has been entirely dependent on the health service contributing to the clean-up. Norsk helsennett contacted all businesses that had requested prescriptions, where errors had been found.
Grundt explains that there are several factors that have contributed to the fact that it has taken time to rectify something so serious.
– The incident occurred just before the summer holidays, and the work on rectification hit holiday closures in several places. There have been challenges with effective information flow at the supplier who was supposed to follow up on his customers. In order to ensure equal and unambiguous information, in week 39 the Directorate of Health sent out letters to the businesses with remaining prescriptions, he says.
Five weeks later, not all of these have followed up.
In addition to the almost 2,000 active prescriptions that were found with errors, 4,000 older prescriptions have been identified that have the same type of error. In September, a cleaning job started to remove the dosage from the older prescriptions with the error in the core journal, so that the error cannot be continued from there if such an older prescription is activated again.
Could sevenfold doses
According to the report, the error was in a patient record system Hdir’s status update. It meant that renewed or imported prescriptions to the prescriber had the dosage of medicine changed to a standard daily dosage. This applied to certain medicines that are taken as injections, and Norsk Helsenett published a list of these. If the error was not detected, it could mean, for example, that a patient followed the dosage the system had changed, and then mistakenly took the injection every day, when it should only be taken once a week.
– Is it known whether such a serious error in the e-prescription could have resulted in loss of life and health after incorrect dosing?
– We are not aware of this, related to this case, replies Grundt.
– What is being done to prevent this from happening again?
– Work has started to evaluate the incident with a view to learning and improvement measures, among other things to prevent something similar from happening.
Responsible for the error
The error was not discovered by the record supplier itself, but by health personnel in a business who notified the Norwegian Health Network (NHN). NHN does not yet wish to say which supplier is concerned, or whether the case has had any consequences for those responsible.
– The cooperative climate in the value chain around e-prescription is important for patient safety in Norway. It is important that the actors can have a good dialogue about challenges and error situations. Therefore, we do not wish to comment on matters concerning individual suppliers. NHN is working well together with the actors involved to correct the error, writes director Odd Martin Solem for the Health Personnel division in an email to NTB.
according to Municipal Report it was the billion-dollar group EG, which owns the patient record Infodoc Plenario, that was behind the dosing errors.
#error #eprescriptions #fixed
**Interview with Bjørn Guldvog, Director of Health, on E-Prescribing System Issues**
**Interviewer**: Thank you for joining us today, Bjørn. Recently, there have been major concerns regarding the Swedish e-prescribing system. Can you briefly explain the nature of the error that was discovered?
**Bjørn Guldvog**: Thank you for having me. The issue stemmed from the electronic medical records system not being correctly configured according to the guidelines outlined in the pharmaceutical module. This misconfiguration resulted in the incorrect dosage of medications being prescribed, which poses a significant risk to patient safety.
**Interviewer**: That sounds alarming. When was this issue first identified, and what has been done since then to address it?
**Bjørn Guldvog**: The error was first discovered on June 13. Initially, we were optimistic that the error could be rectified quickly, and we recognized the contributions of businesses and practitioners in eliminating these problematic e-prescriptions. However, four months later, we still have about 37 remaining prescriptions in the system that contain this serious error.
**Interviewer**: What are the factors contributing to the prolonged rectification process?
**Bjørn Guldvog**: Several factors have come into play. The error emerged just before the summer holidays, causing delays in rectification efforts due to holiday closures. Additionally, there have been issues with information flow from the supplier responsible for assisting businesses in addressing the error. We’ve since sent out letters to clarify the situation and encourage businesses to follow up on outstanding prescriptions.
**Interviewer**: It’s troubling to hear that there are still active prescriptions with these errors. According to reports, there were almost 2,000 active prescriptions identified with errors and around 4,000 older prescriptions flagged as well. What steps are being taken to resolve these older prescriptions?
**Bjørn Guldvog**: We initiated a cleaning process in September to remove erroneous dosages from older prescriptions in the core journal. This is to ensure that if an older prescription is reactivated, it won’t inadvertently convey the incorrect dosage. It’s an ongoing effort to safeguard patient health.
**Interviewer**: It seems like a complex issue with serious implications. How do you reassure patients and healthcare providers while this situation unfolds?
**Bjørn Guldvog**: Communication is key. We are actively ensuring that all stakeholders remain informed and encouraged to report any discrepancies they may encounter. Our priority is patient safety, and we are working diligently to restore the integrity of the e-prescribing system.
**Interviewer**: Thank you for your insights, Bjørn. We hope to see improvements soon in the e-prescribing system for the safety of all patients.
**Bjørn Guldvog**: Thank you for bringing attention to this important issue. We are committed to resolving it swiftly.
