Wrong prescription in second GPASS record error

A second patient has been given the wrong prescription in a repeat of a printer error at a Glasgow practice which computer suppliers GPASS described as an isolated incident when it first happened.

The first error happened in January at the C Wing practice in Woodside Health Centre, Glasgow, when two prescriptions went to be printed at the same time and patient B’s prescription was wrongly printed with patient A’s medication.

Last month another patient, this time a 90-year-old woman, wrongly received a prescription for phenobarbiturates.

GPASS says it has now developed a permanent fix for the problem which it describes as a “relatively rare record deadlock situation” and the fix has been installed in the C wing practice.

A spokesman for GPASS told EHI Primary Care that the company had not installed a permanent fix after the first error but had developed a modification to the software, to reduce the load on the database in an attempt to reduce the number of occurrences of deadlocks, while working on a permanent solution.

He added: “At the time of the reported recurrence, GPASS had already developed additional checking routines in Release 5.6 to remove the possibility of the scenario happening again and had planned to release this at the end of May to all practices.

“However, as the issue had reappeared, GPASS felt it prudent to apply these changes to Release 5.5. This was carried out and was issued to the practice at the end of April. Subsequently, we have had no further reports of any anomalies from the practice.”

The spokesman said all practices had also been informed about the error and a diagnostic print script was made available but no other instances of the problem were found. A patch has been developed for release with next GPASS update.

John McIldowie, practice manager at the Glasgow surgery, told EHI Primary Care: “A 90 year old lady was given a prescription with the previous patient’s medication on it which could have had potentially fatal consequences but luckily she spotted the error. We have been very fortunate that on both occasions the error has been noticed.”

McIldowie said the surgery had changed its working practices since the first incident, following GPASS advice, so that each prescription was printed individually rather than going into a print queueing system, but the error had still occurred.

The practice has wanted to move to another computer system for a long time and hopes that the announcement last month that GPs can now change systems will allow it to do so this year.

McIldowie added: “We’re are waiting on the guidance to fill in the business case. We have wanted to move for some time and hopefully that will now happen. We are extremely unhappy with GPASS but until we can move forward to another system we are in their hands.”

The deal on system choice made by the Scottish Executive Health Department (SEHD) and the BMA’s Scottish General Practitioner Committee was announced at last month’s Scottish LMCs’ conference. It follows considerable pressure from Scottish GPs, 85% of whom use GPASS.

GPs will be allowed to move systems providing that certain conditions are met including an agreement that any new system must use a central data server. GPs have until 31 October 2005 to finalise their business case this year and it is likely that GPs will be offered a similar opportunity to change systems in 2006. More information on the choice initiative is due to be issued by the SEHD soon.

In the mean time GPASS, which is still expected to be used by a large majority of Scottish practices at the end of the year, has outlined its plans to introduce its new system GPASS Clinical.

Ron Anderson, head of national IM&T programmes, told GPASS users in his latest monthly update that a number of strands of work were progressing in parallel including the development of the new GPASS Clinical Interface, a SQL 2000 compatible version of GPASS, release 5.6 of the existing GPASS system and the initial implementation of thin client based, managed services for around 100 practices.

Priority for upgrading to GPASS Clinical is to be given to practices who have moved on to the new thin client-based, managed services system and six practices are currently having the system installed.

Once this is completed GPASS Clinical will be rolled out to 100 pilot sites by late summer.

Release 5.6 will also be available as a normal upgrade for those practices not involved in the managed services rollout and this is due to start at the end of May.