By Tony Collins
The Portsmouth News reported yesterday that 77 year-old Joan Dixon died on Ashling ward at St Richard’s Hospital in Chichester after a large overdose of heart medication.
Had the proposed dose of medication gone through an e-prescription system would it have sounded an alarm before such an inappropriately large individual dose could be administered?
The Portsmouth News reported that a week-long inquest heard how junior doctor Prashen Pillay prescribed Joan Dixon with Digoxin for an irregular heartbeat.
Dr Pillay had meant to prescribe 250 micrograms of the heart-slowing drug, but instead wrote mg for milligrams.
Dr Pillay, who had been working at the hospital for about eight weeks, said: ‘Somewhere between my brain and my right hand it got turned from micrograms into milligrams.’
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Of course a good ePrescribing and Administration process would have prevented this event.
Its a bit like asking “Would Anti Lock Braking Systems help make most cars stop in a shorter distance in an emergency, when the care is being driven by an ordinary driver?”
Cars now have ABS as standard, so we simply have to use them.
Far fewer people die in RTAs than “accidentally” in hospitals because of drug related errors.
Anti Totally Wrong Dose Sofware should be standard in the NHS.
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Might you be looking in the wrong place?.
If an e-prescription system could have picked it up, presumably, 250mg – 1000x the intended dose – might have flagged up a few alarms with the person administering the medicine, providing of course, they were working in an organisation where it was OK to ask.
If they were not, an e-prescription system might exacerbate underlying problems, reducing opportunities to think, exercise professional knowledge and so forth.
We all know about the computer never being wrong or in which it is difficult to change erroneous data (change control procedures probably requiring a meeting of three departments, in four weeks time, if you are lucky…)
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All you say is true. But what if the e-prescription system alarm had been in essence a back-up, to guard against human error – like a stick shaker on an aircraft which does nothing to fly the plane but is a last-resort warning the plane is about to enter a potentially fatal stall.
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