Release Notes RTI 5122 Patient Safety and Quality Improvement Service Right to Information application 5122 – Documents related to any cases where ieMR systems and software have been investigated because of: (a) the incorrect amount of drugs administered to patients and/or (b) the incorrect recording of the amount of drugs administered to patients (c) documents related to any cases where this has resulted in harm to patients Purpose of report Provide applicant of RTI 5122 details of incidents reported in the RiskMan system meeting the search as detailed below. Data source • • • • Any data presented was extracted from RiskMan and is self‐reported by Hospital and Health Service (HHS) staff; Data is based on the ieMR being investigated. HHSs have confirmed that these matters may have resulted in an investigation of the ieMR, however the incident may not be related to use of the ieMR. Riskman is designed to enable reporting, investigation and management of clinical incidents and consumer feedback reported/received by HHS staff. The data was current in RiskMan as of 31 May 2019. Search Criteria • • • • Date range: 1 January 2018 to 23 April 2019 (Incident Date) Incident type = Medication Medication Process = Administration and Prescribing Contributing factors = eHealth/ieMR Search Methodology • • • RiskMan data was extracted and checked by Systems team, Patient Safety and Quality Improvement Service (PSQIS). Duplicate records were removed Records were then reviewed by Systems team, PSQIS for relevance based on information recorded in RiskMan. Search Results • Out of 95 records that met the search criteria the following were deemed relevant based on information recorded in RiskMan o ieMR incorrect Medication recording – 49 records o ieMR incorrect Medication amount – 46 records o ieMR not used correctly – 45 records o ieMR difficult to use – 32 records Interpretation notes The vast majority of care delivered in hospitals and by other health services in Queensland is very safe and effective. However, despite excellent skills and best intentions of our staff, occasionally things do not go as expected. When this happens, it is distressing for patients, families and staff, particularly when the consequence is severe. Publicity around these events can also cause the community to lose trust in their healthcare system. Queensland Health has worked hard to develop a patient safety culture that actively encourages staff to report clinical incidents and see these as opportunities to learn about and fix problems. The analysis of these incidents helps us better understand the factors that contribute to patient incidents, and implement changes aimed at improving safety. While some people may interpret reports of clinical incidents as a sign of poor safety, we view incident reporting as an indicator of a good patient safety culturethat ultimately leads to better patient care i.e. staff are willing to report incidents to actively pursue implementation of actions in order to minimise the potential for the reoccurrence of a similar incident in the future. Interpreting numbers of clinical incidents, comparing the number of clinical incidents between HHSs, or using the number of clinical incidents as indicators of performance is not advised due to: • a degree of clinical subjectivity in deciding whether an adverse outcome is a clinical incident i.e. what is reasonably expected is different from one clinician to the next, as well as what is expected by the patient/family. For example, a death may not have been reasonably expected and therefore met the definition of a SAC1 incident, but is later determined to have been the result of an underlying condition. Consistent with best practice across the world, it is important to us to have a reporting system that captures a broad scope of adverse patient outcomes that could be potentially preventable so that we can continue to learn and improve. • Classification of an adverse patient outcome as a clinical incident does not describe ‘negligence’ or ‘fault’ on behalf of our staff or systems. • Not all clinical incidents are preventable. • Higher incident reporting rates are generally accepted as an indicator of a positive and transparent safety culture, rather than a marker of less safety care. • SAC 2, SAC 3 and SAC 4 clinical incidents are not mandatorily required to be reported. Severity Assessment Code (SAC) Definitions SAC 1 - Death or permanent harm which is not reasonably expected as an outcome of healthcare SAC 2 - Temporary harm which is not reasonably expected as an outcome of healthcare SAC 3 - Minimal harm which is not reasonably expected as an outcome of healthcare SAC 4 - Near miss which is not reasonably expected as an outcome of healthcare Release Notes RTI 5122 - 2 - Confirmed level of harm Summary CAIRNS AND Aug 2018 HINTERLAND Harm temporary Innisfail Hospital (minor) Harm temporary Cairns Hospital (minor) CHILDREN'S HEALTH Jan 2018 QUEENSLAND Queensland Children's Hospital CHILDREN'S HEALTH Mar 2018 QUEENSLAND CHILDREN'S HEALTH Apr 2018 QUEENSLAND CHILDREN'S HEALTH Apr 2018 QUEENSLAND CHILDREN'S HEALTH Apr 2018 QUEENSLAND Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) CHILDREN'S HEALTH Jun 2018 QUEENSLAND R CHILDREN'S HEALTH Jun 2018 QUEENSLAND CHILDREN'S HEALTH Jul 2018 QUEENSLAND CHILDREN'S HEALTH Aug 2018 QUEENSLAND Medication: Process Pt found unresponsive with 'low' blood sugar level Deterioration Patient charted for another patients medication list - patient received these medications Medication Medication Pt usual carb ratio at home is 1 unit of novorapid per serve of carbhohydrate. However insulin medication chart was prescrobed as 2 units per serve of carbohydrate Medication incorrect dose of sodium phenylbutyrate given DOH RTI 5122 Medication: Issue Medication Medication Contributing factors Communication / documentation Inadequate documentation
Communication / documentation Inadequate verbal communication / handover
eHealth / ieMR Access to information
Haemovigilance factors Administration of product
Haemovigilance factors Prescribing / ordering eHealth / ieMR Inappropriate My Health Record management
Workforce Time pressure
Workforce Workload Care plan Inappropriate care plan
Communication / documentation Inadequate documentation
Communication / documentation Ineffective verbal communication / handover
eHealth / ieMR Incorrect IeMR
Haemovigilance factors Administration of product
Haemovigilance factors Prescribing / ordering Prescribing Ceased medicine administered Incorrect patient Administration Clinical communication
Clinical process
Me dication Administration Incorrect dose Assessment Assessment not completed
Care plan Care plan not followed
Communication / documentation Inadequate documentation
Communication / documentation Inadequate verbal communication / handover
Communication / documentation Ineffective verbal communication / handover
Communication / documentation Missing documentation
Consent Incomplete
eHealth / ieMR Access to information
eHealth / ieMR Incomplete IeMR information
Haemovigilance factors Administration of product
Haemovigilance factors Prescribing / ordering
Knowledge / skills Decision support not used
Knowledge / skills Training inadequate
Procedures / guidelines Could not locate policy / guideline
Procedures / guidelines No relevant procedures / guidelines to follow Medication Administration Incorrect dose Incorrect time or frequency of administration Medication Administration Incorrect dose Medication Medication Prescribing Medication Medication Prescribing eHealth / ieMR Incorrect IeMR
Knowledge / skills Skill gap not recognised Communication / documentation Missing Incorrect time for documentation
eHealth / ieMR Incomplete IeMR administration information eHealth / ieMR Incorrect IeMR
Equipment / consumable Unfamiliar
Equipment / consumable User error
Procedures / guidelines Incorrect Other prescribing issue process used IeMR Advanced - Missed dose 20 units Levemir at 2000hrs 25/6/18 Medication Medication Administration Omitted dose IeMR Advanced - Nil task in MAR in iEMR for 0400 dosage to be administered Medication Medication Prescribing eHealth / ieMR Incorrect IeMR
Workforce Inattention / distraction
Workforce Time pressure Communication / documentation Missing documentation
eHealth / ieMR Incomplete IeMR Other prescribing issue information Missed dose of Thyroxine over weekend Medication Medication Prescribing Medicine not prescribed eHealth / ieMR Incomplete IeMR information Dosage error in prednisone Medication Medication Prescribing Incorrect dose eHealth / ieMR Incorrect IeMR ieMR Advanced - Clonidine administered at incorrect times 2x days in a row Medication Pts rapid rehydration fluid was given at a higher amount than required. Pt ended up getting 40ml/kg of fluid Medication IeMR Advanced - Commencement date for PCA incorrectly ordered ieMR Advanced - Possible prescribing error. Possible dosage max exceeded. Difficult to identify through ieMR MAR/ MAR Summary total doses in 24h TI CHILDREN'S HEALTH May 2018 QUEENSLAND Harm temporary (minor) Classification Clinical communication
Deteriorati on
Medicati on Administration R CAIRNS AND Apr 2018 HINTERLAND Primary incident type E Facility EL EA S Incident ID Incident date Hospital and Health Service 1 of 7 eHealth / ieMR Access to information CHILDREN'S HEALTH Sep 2018 QUEENSLAND CHILDREN'S HEALTH Sep 2018 QUEENSLAND CHILDREN'S HEALTH Oct 2018 QUEENSLAND CHILDREN'S HEALTH Oct 2018 QUEENSLAND CHILDREN'S HEALTH Oct 2018 QUEENSLAND CHILDREN'S HEALTH Nov 2018 QUEENSLAND Queensland Children's Hospital Harm temporary (minor) Queensland Children's Hospital Queensland Children's Hospital Queensland Children's Hospital Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Queensland Children's Hospital Queensland Children's Hospital Harm temporary (minor) Harm temporary (minor) Queensland Children's Hospital Harm temporary (minor) CHILDREN'S HEALTH Nov 2018 QUEENSLAND Queensland Children's Hospital Harm temporary (minor) Queensland Children's Hospital Queensland Children's Hospital Harm temporary (minor) Harm temporary (minor) CHILDREN'S HEALTH Dec 2018 QUEENSLAND Medication Administration Incorrect dose Patient given second gentamicin dose too early and precribed incorrectly Medication Medication Prescribing Incorrect dose 2pm dose of clonidine was ordered on the MAR to start at 2pm /9 but ordered as 'daily' instead of 24 hourly therefore task for next dose drops at 8am each day (default daily time). Clonidine 100mcg was given at approx 6am and a further 75mcg was given at 8am for 3 days. Medication CHILDREN'S HEALTH Jan 2019 QUEENSLAND Queensland Children's Hospital Harm temporary (minor) Prescribing Incorrect time for administration Medication Prescribing eHealth / ieMR Access to information
Knowledge / skills Decision support unavailable
Knowledge / Other prescribing issue skills Lack of or inadequate safety awareness Weaning planresults in 7 hour of no presription for 4 hourly medication Medication Medication Prescribing Other prescribing issue eHealth / ieMR Incomplete IeMR information PCA: INCORRECT MORPHINE NCA DOSE RUNNING FOR APPROX 1 DAY IN PICU Medication Medication Administration Incorrect rate of administration eHealth / ieMR Incomplete IeMR information night time levemir dose signed off as given in the morning in PICU Medication Medication Administration Incorrect time or frequency of administration 5 units of Levemir administered - Order is for 0.5 Units of Levemir Medication Medication Administration Incorrect dose eHealth / ieMR Access to information
eHealth / ieMR Staff training inadequate
Haemovigilance factors Deliberate clinical decision
Haemovigilance factors Other Communication / documentation Inadequate documentation
eHealth / ieMR ieMR decision support unavailable Medication Clinical communication
Clinical process
Me dication Prescribing Medicine not prescribed Communication / documentation Inadequate documentation
Communication / documentation Missing documentation
eHealth / ieMR Access to information
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Incorrect IeMR Medication Clinical process
Me dication Administration Incorrect rate of administration Patient was not administered evening dose of Tacrolimus and morning dose was not charted and administered late. Phase 2 of the NAC infusion was made up correctly but input into the pump incorrectly, therefore patient was receiving significantly lower dose Pt was given extra dose of lorazepam Medication Medication Administration Incorrect time or frequency of administration Long term medication not charted Medication Medication Prescribing Medicine not prescribed eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow
Workforce Time pressure Communication / documentation Missing documentation
eHealth / ieMR Incorrect IeMR
Physical environment Environmental distractions eHealth / ieMR ieMR decision support unavailable
eHealth / ieMR Incomplete IeMR information Patient reviewed by QSIS registrarf on /01/2019, Inactivated vaccines prescribed, approved, iemr notes state vaccines should preferably be given as an inpatient.Same not administered.Pharmacist flagged in ieMR note inactatived vaccines due. Vaccines prescribed on a cross encounter ? not seen. Medication Medication Administration Omitted dose eHealth / ieMR Access to information
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Staff training inadequate Incorrect dose eHealth / ieMR Decision support overruled
eHealth / ieMR ieMR decision support unavailable
eHealth / ieMR Staff training inadequate
eHealth / ieMR System defect experienced
eHealth / ieMR Workflow CHILDREN'S HEALTH Feb 2019 QUEENSLAND Queensland Children's Hospital Harm temporary (minor) Pt with ALL (2YO) admitted to ED with ?PORT infection - weight documented in iemr in ED 25.5kg (actual body weight 15.5kg). Piptaz and Vanc doses calculated on 25.5kg and 5 doses of each administered before dosing error was identified. Medication CHILDREN'S HEALTH Feb 2019 QUEENSLAND Queensland Children's Hospital Harm temporary (minor) Epidural orders completed against the wrong patient encounter, prepared using order from order screen not MAR R Medication eHealth / ieMR Decision support overruled
eHealth / ieMR ieMR - Alarm / alert fatigue
eHealth / ieMR Staff training inadequate
Haemovigilance factors Prescribing / ordering
Knowledge / skills Lack of or inadequate safety awareness
Knowledge / skills Training inadequate Patient on ketogenic diet. Noted on rounding to be prescribed liquid medications. Medication TI CHILDREN'S HEALTH Dec 2018 QUEENSLAND Medication R CHILDREN'S HEALTH Nov 2018 QUEENSLAND Issues with medicine - confusion with product, capsules missing, ?wrong dose given. Communication / documentation Missing DOH RTI 5122 documentation
eHealth / ieMR Incomplete IeMR information
Procedures / guidelines No relevant procedures / guidelines to follow eHealth / ieMR ieMR decision support unavailable
Procedures / guidelines Incorrect process used E CHILDREN'S HEALTH Sep 2018 QUEENSLAND Harm temporary (minor) Harm temporary (minor) EL EA S CHILDREN'S HEALTH Sep 2018 QUEENSLAND Queensland Children's Hospital Queensland Children's Hospital Medication 2 of 7 Medication Prescribing Clinical communication
Medication Prescribing Other prescribing issue eHealth / ieMR Incorrect IeMR DOH RTI 5122 Queensland Children's Hospital (None Entered) Medication Medication Discharge: Patient discharged from PICU to 11A Clinical on Sunday afternoon. Regular medicine process
Me Levetiracetam was not prescribed on iemr Clinical process dication Prescribing Medicine not prescribed Medication: 2 doses of paracetamol given within 20mins Medication Duplicate order eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow CHILDREN'S HEALTH Apr 2019 QUEENSLAND Harm temporary (minor) Harm temporary (minor) Apr 2019 GOLD COAST Gold Coast University Hospital Harm temporary (minor) Pt was incorrectly given 100mg of Sildenafil at 1400hrs Harm temporary (minor) On ward round pip-taz planned to be ceased and meropenem prescribed. Order discontinued, confirmed by Pharmacist Ron Nightingale that yes, patient is only on Lincomycin, meropenem and vancomycin. Yet pip-taz order remained active and continued to be administered unnecessarily. Medication Medication Medication not given this morning due to dose not ordered No night time order for lantus Aug 2018 MACKAY Mackay Base Hospital Oct 2018 MACKAY Mackay Base Hospital Oct 2018 MACKAY Mackay Base Hospital Nov 2018 MACKAY Mackay Base Hospital Dec 2018 MACKAY Mackay Base Hospital Jan 2019 MACKAY Harm temporary (minor) Harm temporary (minor) Mackay Base Hospital Patient given a total of 7000mg in a 24 hour period Incorrect dose eHealth / ieMR Staff training inadequate
Procedures / guidelines Not followed Medicine not ceased Access Unable to access at time required
Communication / documentation Missing documentation
eHealth / ieMR Incorrect IeMR Medication Clinical communication
Medication Administration Omitted dose Communication / documentation Inadequate verbal communication / handover
Communication / documentation Missing documentation
eHealth / ieMR Access to information Medication Medication Prescribing Medicine not prescribed eHealth / ieMR Access to information
eHealth / ieMR Staff training inadequate Assessment Screening not completed
eHealth / ieMR Decision support overruled
Procedures / guidelines Not current best practice
Procedures / guidelines Not followed Medication Medication Administration Prescribing Medication Medication Administration Incorrect time or frequency of administration Medication Medication Prescribing eHealth / ieMR Access to information
eHealth / Other prescribing issue ieMR Staff training inadequate Incorrect dose eHealth / ieMR Staff training inadequate
Workforce Inappropriate staff levels
Workforce Skill mix
Workforce Workload Incorrect medicine eHealth / ieMR Workflow
Procedures / guidelines Not followed Ceased medicine prescribed eHealth / ieMR System defect experienced
eHealth / ieMR Workflow
Equipment / consumable Suitability for purpose
Equipment / consumable Usability Medicine not prescribed eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow
Knowledge / skills Skill gap not recognised Omitted dose eHealth / ieMR Access to information Medicine not prescribed eHealth / ieMR Incomplete IeMR information
Procedures / guidelines Checklist not followed
Workforce Inattention / distraction could not order stat dose of IV insulin Patient given 18 units instead of 8 units of novorapid penfill at dinner. Carbs counted correctly but correction given when not needed Medication Clinical process
Me dication Administration Pt given wrong medication and wrong dose Medication Medication Harm temporary (moderate) Metformin order (1000mg/day) suspended medication continued to be administered for multiple days. Patient now has new injury. Medication Jan 2019 METRO NORTH Apr 2018 METRO SOUTH Harm temporary (minor) R Mackay Base Hospital PAH-Building 1 Prescribing Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) Harm Caboolture temporary Hospital Campus (minor) Jan 2019 MACKAY Medication EL EA S Mackay Base Hospital TI Mar 2018 MACKAY Harm temporary (minor) Harm temporary (minor) R Feb 2018 MACKAY Mackay Base Hospital Medicine not prescribed Communication / documentation Missing documentation
eHealth / ieMR Incorrect IeMR
eHealth / ieMR Workflow
Knowledge / skills Decision support unavailable
Person factors Social history Queensland Children's Hospital Queensland Children's Hospital CHILDREN'S HEALTH Apr 2019 QUEENSLAND Prescribing Communication / documentation Inadequate documentation
Communication / documentation Missing documentation
eHealth / ieMR Incomplete IeMR information
Equipment / consumable Inadequate presentation / packaging E CHILDREN'S HEALTH Feb 2019 QUEENSLAND patient admitted to PICU post operative after 18:00, with pain buster. The pain buster only has ropivaciane 0.2% - and not charted in the iemR by theatre staff No Novorapid doses charted for doing chart review Medication Administration Prescribing /1/18 when medication not given for 24 hours Dose for /4 mane and nocte not prescribed and Nursing staff did not pick up error so no insulin was given for /4 Medication Medication Medication 3 of 7 Medication Prescribing Clinical process
Me dication Administration Medication Prescribing Apr 2018 METRO SOUTH PAH-Building 1 Harm temporary (minor) Apr 2018 METRO SOUTH PAH-Building 1 Apr 2018 METRO SOUTH PAH-Building 1 Jun 2018 METRO SOUTH Jul 2018 METRO SOUTH Jul 2018 METRO SOUTH Jul 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Aug 2018 METRO SOUTH Prescribing nil insulin ordered Pt administered buscopan rather than the ordered glucagon for a PSMA scan. Only clinical reason for glucagon over buscopan was due to the pt having a CABG previously, nil arrhythmias. Medication Medication Prescribing Medicine not prescribed Medication Medication
Patient identification Administration Incorrect medicine High dose of warfarin for therapeutic INR Medication Medication Prescribing Incorrect dose Patient was charted for a double dose of 320mg of Gentamicin Medication Medication Prescribing Incorrect dose eHealth / ieMR Incomplete IeMR information Assessment Assessment not completed
Communication / documentation Inadequate documentation
eHealth / ieMR Incorrect IeMR
Procedures / guidelines Not current best practice Patient received wrong dose of Lantus & Novorapid. Medication Prescribing Incorrect dose eHealth / ieMR Incomplete IeMR information Medicine not prescribed eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Incorrect IeMR
Knowledge / skills Induction not adequate
Knowledge / skills Skill gap not recognised
Knowledge / skills Training inadequate Incorrect dose eHealth / ieMR Incomplete IeMR information
Person factors Medical history Medication insulin dose not charted and not give Monday morning Patient ordered 100mg Tramadol IR. Same administered. Patient narcotised and naloxone administered. Medication Medication Medication Logan Hospital Logan Hospital Prescribing Assessment Assessment not completed
Assessment Screening not completed
eHealth / ieMR Incorrect IeMR Prescribed quantity of 250mL and put quantity as 1 bottle. Medication Medication Prescribing Clinical process
Me dication Prescribing Prescribed quantity of 250mL and put quantity as 1 bottle. Medication Medication Prescribing Patient had this administered but it was not documented in MAR Medication Medication Administration eHealth / ieMR Incorrect IeMR
Knowledge / skills Other prescribing issue Lack of or inadequate safety awareness Communication / documentation Inadequate Administration not documentation
eHealth / ieMR Staff training recorded / signed inadequate Regular order for 50mg mane dose of clozapine not ceased and con-current powerplan started Medication Medication Prescribing Duplicate order eHealth / ieMR Incomplete IeMR information Regular order for 50mg mane dose of clozapine not ceased and con-current powerplan started Medication Medication Prescribing Duplicate order eHealth / ieMR Incomplete IeMR information Regular order for 50mg mane dose of clozapine not ceased and con-current powerplan started Medication Medication Prescribing Duplicate order eHealth / ieMR Incomplete IeMR information Regular order for 50mg mane dose of clozapine not ceased and con-current powerplan started Medication Medication Prescribing Duplicate order eHealth / ieMR Incomplete IeMR information Clozapine titration where powerplan and regular orders were charted Medication Medication Prescribing Duplicate order eHealth / ieMR Incomplete IeMR information Harm temporary (minor) Dalteparin doses not given by nurse as they recorded patient was mobilising. Treatment was prescribed due to superficial thrombophlebitis Medication Medication Administration Omitted dose eHealth / ieMR Incomplete IeMR information Harm temporary (minor) Dalteparin doses not given by nurse as they recorded patient was mobilising. Treatment was prescribed due to superficial thrombophlebitis Medication Medication Administration Omitted dose eHealth / ieMR Incomplete IeMR information R Aug 2018 METRO SOUTH Harm Redland Hospital - temporary Main Building (minor) Harm temporary PAH-Building 1 (minor) Harm Logan Hospital - temporary Building 1 (minor) Harm Logan Hospital - temporary Building 1 (minor) Harm temporary QEII Hospital (minor) Harm temporary Logan Hospital (minor) Harm temporary Logan Hospital (minor) Harm temporary Logan Hospital (minor) Harm temporary Logan Hospital (minor) Harm temporary Logan Hospital (minor) Medication R Jun 2018 METRO SOUTH Harm Redland Hospital - temporary Main Building (minor) Harm temporary PAH-Building 1 (minor) Medication TI May 2018 METRO SOUTH Harm temporary (minor) Harm temporary (minor) eHealth / ieMR Incorrect IeMR
Procedures / guidelines Checklist not followed
Workforce Inattention / distraction pt missed dose of novarapid E PAH-Building 1 DOH RTI 5122 eHealth / ieMR Incomplete IeMR information
Procedures / guidelines Checklist not followed
Workforce Inattention / distraction Medicine not prescribed EL EA S Apr 2018 METRO SOUTH Harm temporary (minor) 4 of 7 eHealth / ieMR Incorrect IeMR
Knowledge / skills Other prescribing issue Lack of or inadequate safety awareness Logan Hospital Sep 2018 METRO SOUTH Logan Hospital Nov 2018 METRO SOUTH QEII Hospital Harm temporary (moderate) Harm temporary (minor) Harm temporary (minor) Nov 2018 METRO SOUTH PAH-Building 1 Dec 2018 METRO SOUTH PAH-Building 1 Dec 2018 METRO SOUTH PAH-Building 1 Harm temporary (minor) Harm temporary (minor) Harm temporary (moderate) PAH-Building 1 Harm temporary (minor) Jan 2019 METRO SOUTH Jan 2019 METRO SOUTH Jan 2019 METRO SOUTH Prescribing Patient admitted to ED on /9/18. Patient was on clozapine in community (450mg nocte). Dose not charted /9/18. Dose charted for /9/18 but not given. Dose re-titration as dose withheld >48 hours. Medication Medication Administration omitted dose of supplementary insulin Medication Incorrect Bolus of heparin given Medication QEII Hospital PAH-Building 1 Feb 2019 METRO SOUTH QEII Hospital Feb 2019 METRO SOUTH QEII Hospital Medication Administration Clinical process
Me dication Administration Omitted dose eHealth / ieMR Incorrect IeMR Omitted dose eHealth / ieMR Incorrect IeMR Incorrect dose eHealth / ieMR ieMR - Alarm / alert fatigue
eHealth / ieMR Staff training inadequate Medication Medication Prescribing MAR issue: medication variation on dialysis days Medication Medication Prescribing Incorrect dose missed dose Medication Prescribing eHealth / ieMR Access to information
eHealth / Other prescribing issue ieMR System defect experienced medication prescribed on outpatient encounter and did not come across to inpatient encounter Medication patient charted for 32mg of hydromorphone for 0800hrs, N/S given the dose as charted. patient however had the dose last at 1600hrs of previous day. Medication Medication Prescribing eHealth / ieMR Incorrect IeMR
eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow Incorrect time for administration eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Incorrect IeMR
Knowledge / skills Lack of or inadequate safety awareness eHealth / ieMR Incomplete IeMR information
Procedures / guidelines Checklist not followed
Procedures / guidelines Incorrect process used
Workforce Inattention / distraction
Workforce Skill mix
Workforce Use of temporary staff
Workforce Workload pt not charted for regular medications. no clear instructions or documentation for insulin order Clinical Clinical communication communication
Medication Prescribing Medicine not prescribed PRN med charted contraindicated to pt med hx. med charted PRN & also listed as allergy Medication Medication Administration Administered with known allergy Duplicated order Medication Medication Administration Incorrect dose eHealth / ieMR ieMR - Alarm / alert fatigue
eHealth / ieMR Incorrect IeMR Communication / documentation Inadequate verbal communication / handover
eHealth / ieMR Workflow Administration Incorrect rate of administration eHealth / ieMR ieMR decision support unavailable
eHealth / ieMR Incorrect IeMR
eHealth / ieMR Staff training inadequate Heparin 25000 Unit/50ml infusion administered over 30mins Medication Harm temporary (minor) AM n/s checked pt had discontinued insulin order from yesterday novoMix30/70, pt had 4040-35-0. Treating team paged in the AM if they could pls chart the insulin, however no insulin was charted. Pt ended up not getting AM insulin. Medication Medication Prescribing Vancomycin and concurrent NSAIDs and ARB -> AKI Medication Medication Prescribing Double dose of medication Medication Medication Administration Harm temporary (minor) Harm temporary (minor) Incorrect dose Communication / documentation Inadequate verbal communication / handover
Communication / documentation Missing documentation
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Other prescribing issue Workflow Harm temporary (moderate) R Jan 2019 METRO SOUTH Medication R Jan 2019 METRO SOUTH Harm temporary Redland Hospital (minor) Harm temporary PAH-Building 1 (minor) Harm temporary PAH-Building 1 (minor) Medication TI Dec 2018 METRO SOUTH Incorrect methotrexate dose prescribed, dispensed and administered E Sep 2018 METRO SOUTH Harm temporary (minor) EL EA S Sep 2018 METRO SOUTH Logan Hospital Building 1 DOH eHealth / ieMR Incomplete IeMRRTI 5122 information
eHealth / ieMR Incorrect IeMR
Knowledge / skills Lack of or inadequate safety awareness
Knowledge / skills Skill gap not recognised
Procedures / guidelines Incorrect process used
Procedures / guidelines Organisational change
Workforce Inattention / distraction 5 of 7 Medication Medicine not prescribed Drug-Drug interaction Incorrect time or frequency of administration eHealth / ieMR Access to information
eHealth / ieMR Incorrect IeMR
eHealth / ieMR Workflow
Knowledge / skills Lack of or inadequate safety awareness eHealth / ieMR ieMR decision support unavailable
eHealth / ieMR Incomplete IeMR information
Knowledge / skills Lack of or inadequate safety awareness eHealth / ieMR System defect experienced
eHealth / ieMR Workflow Mar 2019 METRO SOUTH PAH-Building 1 Harm temporary (minor) Harm temporary (minor) DOH RTI 5122 eHealth / ieMR Workflow
Person factors Literacy / comprehension
Workforce Inattention / distraction
Workforce Use of temporary staff Medication error Medication Medication Administration Self / carer administration Wrong rate for heparin infusion/confusing medication order. Medication Medication Prescribing eHealth / ieMR ieMR - Alarm / alert Other prescribing issue fatigue
Procedures / guidelines Not followed Patient given 5mg IV Midazolam Medication Medication Administration Incorrect dose Communication / documentation Ineffective verbal communication / handover
eHealth / ieMR Incomplete IeMR information
Procedures / guidelines Not current best practice Missed dose medicaiton during ieMR conversion form paper chart to digital. Medication Medication Administration Omitted dose eHealth / ieMR Access to information Duplicate order eHealth / ieMR ieMR decision support unavailable
eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow E Mar 2019 METRO SOUTH Logan Hospital Building 3 Feb 2019 SUNSHINE COAST SUNSHINE COAST UNIVERSITY HOSPITAL Harm temporary (minor) Patient has not been prescribed or administered regular Lantus (iEMR contributed to error) Medication Medication Prescribing Medicine not prescribed Feb 2019 SUNSHINE COAST SUNSHINE COAST UNIVERSITY HOSPITAL Harm temporary (minor) Patient did not receive ordered bag of Magnesium Medication Medication Administration Omitted dose eHealth / ieMR Incomplete IeMR information eHealth / ieMR Workflow
Procedures / guidelines Documents not supportive of work processes
Procedures / guidelines Organisational change
Procedures / guidelines Work instruction not understood Communication / documentation Inadequate documentation
Communication / documentation Ineffective verbal communication / handover
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Staff training inadequate Harm temporary (minor) Heparin rate increased to 21u/kg/hr instead of 18u/kg/hr due to incorrect interpretation of order in ieMR. Order withheld for longer than clinically indicated. Medication Medication Prescribing Incorrect dose eHealth / ieMR Staff training inadequate
eHealth / ieMR Workflow Harm temporary (minor) Mismanagement of elevated APPT/heparin infusion Prescribing Incorrect or incomplete calculation eHealth / ieMR Staff training inadequate
Procedures / guidelines Checklist not followed Administration Incorrect time or frequency of administration eHealth / ieMR Decision support overruled
Procedures / guidelines Incorrect process used
Procedures / guidelines Not followed Feb 2019 SUNSHINE COAST Feb 2019 SUNSHINE COAST Feb 2019 SUNSHINE COAST Mar 2019 SUNSHINE COAST Mar 2019 SUNSHINE COAST Apr 2019 SUNSHINE COAST SUNSHINE COAST UNIVERSITY HOSPITAL SUNSHINE COAST UNIVERSITY HOSPITAL (None Entered) SUNSHINE COAST UNIVERSITY HOSPITAL Jan 2019 WEST MORETON Ipswich Hospital Medication Medication Prescribing ieMR documentation lacking regarding order and administration of IV fluids Medication Clinical communication
Medication Administration Administration not recorded / signed Medication patient given 2 administrations of 1 g paracetamol within 1.5 hour timeframe Medication Medication Medication Harm temporary (minor) Incorrect dose of intrathecal morphine precribed Clinical on IEMR in Mg instead of Micrograms and no Clinical communication spinal Morphine obs request communication
Medication Prescribing Harm temporary (minor) Mismanagement of elevated APPT/heparin infusion Medication Harm temporary (minor) Patient discharge process was delayed due to complexities associated with discharge process on iemr and delays in O& G discharge and disjointed and complex process. Clinical process
Me dication
Pa Clinical process tient flow Administration Harm temporary (minor) Patient in severe pain unable to be given pain relief, unable to perform required procedure due to copmuter system failure.Nursing staff unwilling to administer any medications as unable to be docummented as computer system was down Clinical process R Apr 2019 SUNSHINE COAST SUNSHINE COAST UNIVERSITY HOSPITAL SUNSHINE COAST UNIVERSITY HOSPITAL SUNSHINE COAST UNIVERSITY HOSPITAL Ward call RMO unclear about how to order insulin in ieMR and inadvertantly ordered medication twice R Feb 2019 SUNSHINE COAST TI Apr 2019 METRO SOUTH EL EA S Feb 2019 SUNSHINE COAST Harm Redland Hospital - temporary Main Building (minor) SUNSHINE COAST Harm UNIVERSITY temporary HOSPITAL (minor) SUNSHINE COAST Harm UNIVERSITY temporary HOSPITAL (minor) SUNSHINE COAST Harm UNIVERSITY temporary HOSPITAL (minor) 6 of 7 Clinical process
Me dication Prescribing Clinical process
De terioration
Medication
Patient flow Administration Communication / documentation Inadequate verbal communication / handover
eHealth / ieMR Access to information
eHealth / ieMR ieMR - Alarm / alert fatigue
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR Incorrect Other prescribing issue IeMR
eHealth / ieMR Workflow Incorrect dose eHealth / ieMR Staff training inadequate
Knowledge / skills Decision support not used
Knowledge / skills Training inadequate Omitted dose eHealth / ieMR Access to information
eHealth / ieMR Incomplete IeMR information
eHealth / ieMR System unavailable or slow
eHealth / ieMR Workflow Omitted dose eHealth / ieMR Incorrect IeMR
eHealth / ieMR Staff training inadequate Feb 2019 WEST MORETON Ipswich Hospital Mar 2019 WEST MORETON Ipswich Hospital Ipswich Hospital Harm temporary (minor) PCA not connected. Medication Medication Administration pt given paracetamol within 6hour time frame as dose given in OT Medication Medication Administration Incorrect dose of administered Medication R TI R Apr 2019 WEST MORETON Harm temporary (minor) Harm temporary (minor) Harm temporary (minor) DOH RTI 5122 Medicine not prescribed Omitted dose Incorrect time or frequency of administration 7 of 7 Medication Communication / documentation Inadequate verbal communication / handover
Communication / documentation Missing documentation
eHealth / ieMR Incomplete IeMR information eHealth / ieMR Workflow
Workforce Time pressure E Ipswich Hospital Clinical communication
Clinical process
Me dication Prescribing EL EA S Feb 2019 WEST MORETON Failure to document chronic conditions and medications led to not being prescribed for 4 days. No scanned into iEMR Medication Administration Incorrect rate of administration eHealth / ieMR Staff training inadequate
Procedures / guidelines Not followed Access Unable to access service
Communication / documentation Ineffective verbal communication / handover
eHealth / ieMR Security of information
eHealth / ieMR Staff training inadequate
Knowledge / skills Training inadequate
Procedures / guidelines Incorrect process used
Teamwork Individual responsibilities not clear
Teamwork Supervision inadequate
Teamwork Unfamiliar team