Glitch a threat to Nelson patients

01:43, Jan 31 2009

Patients' lives are being put at risk by a computer prescribing glitch that may have already led to one Nelsonian's death, some pharmacists say.

Collingwood St Pharmacy owner Gary Chalmers said general practitioners had been accidentally ordering life-threatening doses of drugs using the computer-generated prescriptions.

The problem seemed to be caused by either a computer glitch or inflexibility in the software, he said.

It appeared that if the doctor didn't fill out a dose or indicate how often the medicine should be taken, a default amount - such as "5ml" or "twice daily" - appeared on the prescription, Mr Chalmers said.

He knew of one Nelson patient whose death was likely to have been as a result of the problem, but would not reveal any further details out of respect for the distraught pharmacist involved.

Detective Senior Sergeant Wayne McCoy, of the Nelson CIB, said he could not comment on the case because it was before the coroner.


Mr Chalmers said he blocked an order this week for "one vial daily" of an injectable drug - a potentially lethal dose.

He had another recent error where a prescription had called for a single 5ml dose of eyedrops - a physical impossibility.

Mr Chalmers said the only reason the issue may have been a factor in just one death was that the ordered doses had been "so laughably wrong" that they had been corrected by pharmacists.

He said another problem with the computerised system was that it was hard for doctors to change the types of drugs that were programmed, meaning they would often prescribe a drug that was either discontinued or no longer subsidised by government drug-buying agency Pharmac.

GPs had invested heavily in the new computer system, which was introduced in Nelson about eight years ago. Despite the ongoing problems, they were eager to make it work rather than return to the old manual system, Mr Chalmers said.

Motueka pharmacist Dave Ross said that along with potential overdoses, there was a danger of under-medication. He had recently intervened when a patient was prescribed less than half the necessary amount of an asthma drug.

If the error had not been spotted, the patient would probably have ended up in hospital, Mr Ross said.

Pharmacists were confronted with the errors a few times each day but most were detected, he said.

Pharmaceutical Society of New Zealand national president Chris Budgen said that while the introduction of computerised prescribing had solved problems associated with deciphering GPs' handwriting, it had presented a whole new set of problems.

The legal onus was put on pharmacists to detect any doctors' omissions - with or without computers - and in most instances they were easily spotted, he said.

Software companies could solve a lot of the problems by changing their product, he said.

Nelson GPs' spokesman Graham Loveridge said there was room for change but the computerised system was a vast improvement on handwritten prescriptions and had improved patient safety.

Nelson Bays Primary Health Organisation general practice programme coordinator Margaret Gibbs said she was unaware of the problem. She was working with pharmacists, GPs and the local health board on other problems with computer systems.