Minister admits mislabelled blood problem may be worse than reported

Minister admits mislabelled blood problem may be worse than reported

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“I think it’s wrong to say [the ieMR is] the cause, in fact in all likelihood it’s the reason we’re aware of these errors,” Mr Miles said.

“One of the benefits of digitising our hospitals is it provides a lot of automatic alerting when errors occur.”

Mr Miles said it “would not be unusual to see a level of human error on something like this” but in hospitals without the ieMR, where he said mislabelled blood tests were not flagged and counted as readily.

University of Melbourne chair of anaesthesia Professor David Story told Brisbane Times on Thursday that a mislabelled blood test could see a patient incorrectly diagnosed or miss out on critical treatment.

Professor Story said the introduction of electronic medical records had created additional “complexity” for clinicians ordering blood tests, using separate computers, scanners and printers.

A report produced by national body BloodSafe eLearning Australia in October 2019, which is funded by the National Blood Authority, detailed the impacts of Australia’s national transition to electronic medical records on blood transfusion errors.

The report was developed with advice from transfusion clinical experts nationwide to highlight the impacts of electronic medical records and reduce potential errors.

“Experts in clinical transfusion practice are concerned about the increased number of near-miss and adverse events as a result of the implementation of electronic medical record (EMR) and supporting technology,” the report said.

Opposition health spokeswoman Ros Bates said the public “don’t know how many near misses there have been”.

“One labelling error is one too many and could lead to dire consequences for a patient,” Ms Bates said.

“These labelling errors are dangerous and are completely unacceptable, putting patient care at risk.”

Major hospitals statewide including the Princess Alexandra, Gold Coast University Hospital, Mackay, Cairns and Toowoomba have the ieMR installed.

The Gold Coast University Hospital, where the ieMR went live in April this year, reported 13 suspected mislabelled blood incidents in 2018, and 55 this year to November.

Logan Hospital, where the ieMR went live in December 2017, saw 33 incidents in September to December 2017, then 88 suspected incidents in 2018.

Some hospitals, including Townsville and the PA, reported more than 100 suspected ‘wrong blood in tubes’ cases each year since 2016.

Mr Miles said the state’s hospitals were “constantly striving to reduce errors”.

“No doubt management in those hospitals are looking into whether there are any root causes there,” he said.

“But that’s the benefit of having an electronic system that we are able to see that level of data.”

The report warned a “recurrent theme” was health professionals were not following the basic principles of patient identification when dealing with blood tests and transfusions, with reasons ranging from using complex systems, a sense of false security that electronic medical records were safer, and significant changes to previous processes.

However, it also warned that relying on staff training as the primary method to reduce error was a flawed focus, and systems should be modified to suit people, not the other way around.

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