Safety commission makes findings on incorrect scripts on PCEHR

An independent team that has investigated the circumstances in which incorrect PBS data was added to a Pulse+IT journalist's PCEHR has recommended that the Department of Health and Ageing consider lowering the stringent evidence of identity threshold for the PCEHR helpline, but did not consider making a recommendation to remove PBS data entirely from the PCEHR system.

As reported in May, this reporter discovered that data for two prescriptions had been added to the PBS section of my PCEHR despite them not having been prescribed for me. In my attempts to find out how it happened, I was unable to be assisted by a PCEHR helpline operator as I could not provide enough verification of my identity over the phone, despite having my personal record open at the time.

The Department of Human Services (DHS) launched an immediate investigation, and was able to discover that the scripts were dispensed at a pharmacy close to my home. On all available evidence, it appears that the pharmacist incorrectly selected my record in the dispensing system and sent a claim to the PBS containing my details rather than the real patient's.

As the prescriptions were issued with several repeats, the same drugs were dispensed some weeks later from a different pharmacy, again with my details attached. With my permission, DHS began monitoring prescriptions dispensed in my name and was able to prevent the second lot of scripts from being uploaded to my PCEHR.

DoHA subsequently asked the Australian Commission on Safety and Quality in Health Care (ACSQHC) to further investigate the matter, assess any patient safety issues and make recommendations on how it might be prevented from happening in future.

The commission appointed a team led by Owen Torpy, manager of its PCEHR clinical governance program, along with clinical safety expert and associate director with KPMG, Bernadette Eather, and Meredith Makeham, a general practitioner and conjoint associate professor with an interest in patient safety at the University of NSW's School of Public Health and Community Medicine.

In early July, the team interviewed me at length using the London Protocol, an established process for investigating and analysing clinical incidents. In that interview, I put to the team the view of some in the industry that DoHA should remove PBS data from the PCEHR entirely.

The team has now issued its findings into the incident, including some recommendations to DoHA. The commission has not recommended that it consider removing PBS data, for a number of reasons.

According to Dr Eather, this incident is the only one that has been reported. Pulse+IT has anecdotal evidence that it has happened to other people – usually those who have found a family member's script information on their PCEHR – but none of these people has made a complaint.

As this is the only reported incident and involved just one individual, the commission could not make recommendations on whether PBS data should be removed.

Dr Eather emphasised that PBS data is administrative and not clinical data. She said the team had looked at errors of commission and omission – not just incorrect PBS data being added to the PCEHR, but no prescription data being shown despite a medication having been prescribed and dispensed – for which there is a long list of reasons.

For example, private scripts that are ineligible for PBS payment will not appear, and nor will scripts from Aboriginal Health Services, which are funded differently. There is also a delay in the time a script is dispensed, the claim is sent to Medicare and it being processed.

The National Prescribing and Dispense Repository (NPDR) will hopefully overcome the limitations of the PBS section of the PCEHR and provide clinicians and patients with more up to date and accurate information. The more widespread use of IHIs will also hopefully minimise these sorts of errors.

The team could not come to any definitive conclusion on exactly what happened at the pharmacy where the error occurred, as the pharmacist in question declined to take part in the incident review.

The commission has recommended that DoHA review its policy for evidence of identity once a consumer has already established a PCEHR. In my circumstance, I was unable to pass the 100-point identity check, despite being able to provide my full name, date of birth, address, IHI number, Medicare number and the name and date of my last consultation with a doctor.

It is DoHA policy that the same level of identity verification required to set up a PCEHR – which is exhaustive, for good reason – also be required for enquiries to the PCEHR helpline.

The commission has recommended that this policy be reviewed to allow for more flexibility once a person actually has a PCEHR. It has also recommended that DoHA explore alternative security checks to ensure privacy is maintained but the burden of identification is decreased for consumers with an established PCEHR.

Without the participation of the pharmacist in the London Protocol process, the team could not make a definitive finding on how the error occurred. As such, the commission has recommended that “the PCEHR participation agreement be reviewed to determine how it could be applied in order to support participation in clinical safety analysis for system improvement”.

This reporter is satisfied with the outcome of the investigation. However, I would recommend that any other consumer who has found an error on their PCEHR report it to DoHA. Readers who do not wish to go through this channel can contact me at This email address is being protected from spambots. You need JavaScript enabled to view it..

Posted in Australian eHealth

Comments   

# Oliver Frank 2013-08-16 13:19
"The team could not come to any definitive conclusion on exactly what happened at the pharmacy where the error occurred, as the pharmacist in question declined to take part in the incident review."

So much for pharmacists as highly trained ethical professionals taking responsibility for their actions. Is it too much to expect the pharmacist to be able to say: "I made a mistake. I am human. Other pharmacists have probably made similar mistakes. I am willing to help to look at what went wrong, and how my profession can work to improve the system in order to avoid similar mistakes in the future"?
# Warrren 2013-08-16 17:51
They may have wanted to participate, but you can be sure that the owners, and managers, of the pharmacy risk would have advised them not to.
# yianni serpanos 2013-08-17 08:12
Ironically one benefit here is another check in the event a prescription is issued intentionally under another name... it may not go under the radar. ..
# Robert 2013-08-22 11:16
So it appears it was not the PCEHR at fault but rather the Pharmacist. What would have happened if the PCEHR was not operating and the journalist in question did not have the facility to view her dispensed record. It would have gone unnoticed and maybe even continued until another Pharmacist noticed it....I say like yianni, the PCEHR at least is another excellent check for people to use to safe guard their personal health record.
# Shane 2013-08-22 18:01
I think the fact that the Pharmacy is involved in the input of data into the PCEHR, and integrity and security of the information is seen as paramount, there should be a requirement of the parties to be involved in any investigation.

I liked (note liked) the idea of the PCEHR, but this episode troubles me. The record is of little value if say a pharmacist can make an error like this (if it was them) and it not be considered as important. I think the designers of the protocol surrounding PCEHR have missed an important point here.

I think I might just drop my participation. If all who can add data to my record are bound to accuracy then the PCEHR might as well be a hand full of post it notes.

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