A software glitched has put South Australian medical staff on high alert after it caused digital prescriptions to feature an extra digit.

SA Health alerted nurses in a memo that warned them to be “alert for high-dose medication” due to an error with the Sunrise electronic medical record (EMR).

“This issue can result in the last digit of the medication dose being duplicated prior to order submission, eg 10mg may display as 100mg, 15mg may display as 155mg,” the memo said.

“It is important for all staff to be aware and carefully review all medication orders.”

In a statement to Information Age, SA Health said it was not yet aware of any adverse effects due to the system error and that “risk mitigation strategies” had been implemented.

“As soon as we became aware of the intermittent issue, all sites using the Sunrise system were notified and implemented risk mitigation strategies or business continuity plans,” the state health department said.

“Additional prescription reviews by medical officers, nursing, midwifery and pharmacists are in place while we investigate the root cause of the intermittent issue.

“As well as this, an additional alert has been added to the medication ordering screen.”

Manual processes

A local nurse told Information Age any error would likely have been picked up by the manual processes necessary to fill a prescription: printing it out, getting it signed off by a doctor, and then giving it to the pharmacist.

SA Health said it had introduced an "interim solution" early on Friday morning but still had not uncovered the root cause.

Sunrise EMR is used in four South Australian hospitals as well as two regional health services.

The medical records management software is sold by US company Allscripts.

Allscripts has not yet responded to requests for comment.

Four years out of date

In last year’s state budget, the South Australian government announced it would direct $196.8 million to continue rolling out AllscriptssSunrise EMR and patient administration system (PAS) software across the SA health network.

A 2018 review into the state’s $421 million attempt to digitise its hospitals into a single system found severe issues with the implementation of Allscriptss Sunrise EMR and PAS solutions – including that the software version was “four years out of date”.

It found the expectation that Allscript’s tools would work out of the box was “incorrect” and that the system needed to be re-configured to plug into the various hospitals’ different existing systems.

The review found governance issues including that SA Health chose to implement the Allscripts solution without any expertise in “electronic workflow design and the change and adoption complexities associated with implementing EMRs”.

Along with upgrading the software versions, the review recommended greater training for clinicians and that Allscripts be “re-engaged” for the Sunrise EMR and PAS implementation in hospitals outside Adelaide.