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Yoav Dudkevitch/TPS on 2 August, 2023
120 Patients Exposed to Medication Error During Hospital Software Malfunction
Jerusalem, 5 February, 2024 (TPS) -- Knesset lawmakers briefed by Health Ministry officials on Monday were told 120 hospital patients were exposed to incorrect prescriptions as a result of a software malfunction that had patients scrambling to see their doctors.
Ariela Even, Director of Pharmacy and Technologies in the Government Medical Centers Division of the Ministry of Health, told the Knesset’s Health Committee that after checking 85% of the healthcare institutions affected by the malfunction, 120 patients were given prescriptions not ordered by doctors.
The software, called Chameleon, provides doctors with an overview of all the patients in a given department, along with treatment status, test results and more. The software is used in government hospitals and hospitals belonging to Clalit, Israel’s largest healthcare provider.
The Health Ministry received initial reports from one hospital about errors in patient records in mid-January. Of particular concern were patient discharge documents containing incorrect prescriptions. As the ministry received similar reports from other hospitals, it ordered an investigation.
The ministry directed the hospitals to verify medicines administered or prescribed to patients. It also recommended that anyone hospitalized in the last two months see their doctor to verify the prescriptions in their discharge letters.
According to Even, the malfunction apparently affected only cases where a person was re-hospitalized in the same hospital.
Even explained to the Health committee that the computerized medical file contains a component of regular medications, which are updated according to each visit. To this list, drugs that were not intended for the patient were added — due to an error of still-unknown origin.
The hospitals are now checking which patients received and took the additional medications. All the health funds received the patient lists – and they were asked to verify whether they had taken it.
Even noted that while the drugs were mistakenly added by the computer, in some instances, the medicines were what doctors would have manually prescribed anyway.
Tzafrir Kagan, CEO of Elad Solutions, which developed the software, said that the system is installed and operated in about 80% of the hospitals in Israel, and that the wide and varied use of the system may have caused the malfunction. Kagan told lawmakers that in the event of a malfunction, the customer accompanies the manufacturer as repairs are made to prevent disclosure of private medical records.
Kagan promised to continue updating the software.
