PROVIDENCE – Thanks to a sharp-eyed physician’s assistant at Rhode Island Hospital, a software glitch in prescriptions for patients being discharged has been caught and corrected within a week of being identified.
The software glitch had been ongoing since mid-2010 at some hospitals within the Lifespan system.
The problem occurred when the prescriptions were being printed out as a patient was being discharged; apparently, the notation indicating sustained-release was not printed, according to Lifespan officials. As a result, patients may have received a prescription or instructions for the regular form. Timed release medications are generally taken once a day, while regular formulation of the dose of the medication are taken multiple times over the course of a day.
The affected patients were discharged starting in January 2011 from Newport Hospital, February 2011 from The Miriam Hospital, Rhode Island Hospital and Hasbro Children's Hospital, and July 2010 from Bradley Hospital, according to Lifespan officials.
In response, Lifespan has been contacting some 2,000 patients who may have been affected by this issue to ensure they received the correct form of their medications.
As of Nov. 2, more than 90 percent of the patients had been reached, many of whom were already taking the correct medication, according to Mary Cooper, senior vice president and chief quality officer at Lifespan.
Cooper said that the prescription drugs involved were across a spectrum of medications, including heart medication, painkillers and drugs. According to Cooper, thanks to the implementation of electronic health records, the problem was identified and corrected by many primary care physicians as patients transitioned from the hospital.
“This incident is a prime example of the risks involved in care transitions for hospital patients, especially since primary care providers now rarely attend their own patients in the hospital,” said Dr. Michael Fine, director of the R.I. Department of Health. “This underscores the need for a more robust team approach for care transitions,” said, saying that his agency is working closely with Lifespan to investigate this incident and do a root-cause analysis.
Sen. James E. Doyle II, D-Pawtucket. issued a call for a state review of Lifespan by the Senate’s Government Oversight Committee or its Health and Human Services Committee.
“When an operator of so many hospitals in our state has this many major problems in such a short time, it could be indicative of serious mismanagement,” Doyle said. “I want an independent review of the hospitals it runs in Rhode Island so we can truly feel confident that Rhode Islanders are receiving safe, reliable treatment when they go to the hospital.