Report and Spread Information About Software Risks

A pharmacist told us recently about a major safety issue his hospital had reported to their computer system software vendor that could lead to medication errors, only to learn the vendor was already aware of the issue. Unfortunately, at the time the report was made, the vendor had not yet shared this information with other end users, many of whom had not yet detected the problem. (Users of the vendor’s software product have since been notified of the problem and the company’s plan to correct the problem.)

The vendor had added a new feature with the last release of its software to help identify, by color change on the electronic medication administration record (eMAR), important medications that weren’t administered within a certain timeframe. But a bug in the program allowed a discontinued medication to remain active on the eMAR.

With one patient, the dose of enoxaparin had been changed, and both the new order and discontinued order displayed as active medications for this patient. When tested, the software allowed the nurse to document administration of this discontinued medication.

When the risk of administering discontinued medications was called to the attention of the software vendor, a representative said that the company was already aware of the problem and trying to fix it. Meanwhile, the pharmacist immediately turned off the new overdue medication feature once he realized the problem was reproducible. The software vendor has since placed information about the problem on its website to help communicate the problem to other software users.

We also heard from another pharmacist about a similar problem with a different software vendor. In this case, discontinued prn medications remain active on the eMAR until the end of the shift or day. When the pharmacist notified the vendor about the problem, he learned that the company was already aware of it. Although the vendor was working to fix the problem, it had not notified other end users about this issue and the risk of medication errors.

We suspect that the failure to notify end users about software problems is not unique to these two pharmacy system software vendors. It’s unacceptable for any computer software or technology vendor to have knowledge of a potential patient safety problem with their product and not report it— urgently, if need be—to end users. This is tantamount to a drug company failing, for example, to report a container label error in which the wrong strength was listed.

Be sure to check with your system vendor to learn about its policy for communicating potentially harmful software glitches to users. You should also learn how the vendor has communicated problems in the past, and the timeliness with which they have corrected problems, particularly those that can harm patients.

Also, when you report a potential medication error problem related to computer software, please consider simultaneously forwarding a description of the problem to ISMP. If possible, screen shots to help demonstrate the problem are also useful. We will follow-up with vendors and pass on information as appropriate to other software users through our various publications, including the ISMP Medication Safety Alert!