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