Causes for IT Glitch that Resulted in Patients Receiving Mislabelled Medicines

Assoc Prof Daniel Goh Pei Siong asked the Minister for Health what led to over 100 clinics prescribing the wrong dosage for 800 patients and whether there were any adverse effects for the affected patients.

Following a system upgrade by an information technology (IT) vendor for general practitioner (GP) Connect implemented on 1 September, some GP clinics encountered problems where some medication labels were printed wrongly. While the correct medication and the total quantity of medication were correctly dispensed, the system printed the wrong Unit of Measurement (UOM) on the label. Several clinics were aware of the error and manually corrected the dosage instruction on the label. Once notified, Integrated Health Information System (IHiS), the public healthcare IT agency and owner of the GP Connect system, investigated the incident, informed all affected clinics from 2 September, and provided support to the clinics.

IHiS has been monitoring the situation. No further errors have been reported since 3 September. Affected patients were monitored by the clinics and, to date, there have not been any reports of adverse effects.

Investigations revealed that the IT vendor had made some changes to the application code which resulted in incorrect medication labels being printed. These changes were unrelated to the upgrade. Hence, the user acceptance tests designed to evaluate the upgrade did not pick up the error. The vendor also did not report any errors from the other tests done.

Since the incident, additional rounds of testing have been conducted to ensure that existing functions within GP Connect are working as designed. The "Unit of Measurement" function is also being enhanced to prevent future errors.

IHiS is also thoroughly reviewing testing procedures prior to future software rollouts to prevent such occurrences. In addition, they will step up monitoring of software rollouts and improve their response to better support users.

I thank the Senior Minister of State for the reply. I have two supplementary questions. First, would the Ministry consider putting in place a process encouraging doctors to print out a copy of the prescription for the patient after examination and going through with him the medicines and dosages? That is the first question. The second one, could this same printout be given to the patient so that the dispenser can countercheck against the labels and instructions on the medicines?

Mr Speaker, I would like to thank Ms Joan Pereira for the supplementary questions. The suggestions are reasonable. In fact, variants of this practice are already being done in many clinics. When medications are dispensed in clinics, it is common practice for the doctors to advise patients at the point of prescribing, for example, alerting the patients to any dosage adjustments to their regular chronic medication. And it is also the responsibility of the clinic licensee and doctors to ensure that there is proper process of verifying the prescriptions during dispensing of the medicines to the patients. The Ministry of Health (MOH) will continue to work with practitioners as well as the professional medical bodies to improve patient safety and medication safety and minimise any possible medication dispensing errors in the future.

I thank the Senior Minister of State. Just one question. Would IHiS be held accountable for this error in any way?

I would like to thank Assoc Prof Daniel Goh for the supplementary question. As the error was executed as a result of the IT vendor changing the application code without informing IHiS, the fault actually lies with the IT vendor. I will leave it to IHiS to manage the situation with the respective IT vendor.

Would the Ministry be considering looking at new security measures or new technologies, such as block chain, for example, to ensure the security and immutability of the data so that such sensitive data, such as prescribed medicine, can be assured?

I would like to thank Dr Intan Azura for the supplementary question. With regard to this particular incident, it is a human error whereby a wrong application code was applied. Of course, we will put in place measures to ensure that such errors can be picked up early or even prevented right from the outset.

As to Dr Intan Azura's suggestion of using new technology or block chain technology to enhance the security of such a system, MOH will seriously look into it.