Y2K flaw blamed for Down's Syndrome test errorsgreenspun.com : LUSENET : Grassroots Information Coordination Center (GICC) : One Thread
Millennium Bug blamed for test errors Thursday, 13 September, 2001, 10:16 GMT 11:16 UK
The computer software led to errors in blood test results
The Millennium Bug resulted in more than 150 pregnant women being given incorrect results of a Down's Syndrome test. The computer error during screening at Sheffield's Northern General Hospital meant the women were originally told they were in the low-risk group.
The simple error was disclosed in a 112-page report, commissioned by Professor Lindsey Davies, regional director of public health. She said as a result of the mistake, four Down's syndrome pregnancies went undetected. Two of the women later gave birth to Down's Syndrome babies, while two other women terminated their pregnancies. This was a simple error that shouldn't have happened. If the women had been placed in the high-risk category earlier, they could have undergone an amniocentesis test for Down's Syndrome weeks before, medical experts believe. The later the test is carried out in a pregnancy, the greater the risk to the mother and her unborn child.
The women were tested at nine hospitals in South Yorkshire, Lincolnshire and the East Midlands and the results were sent to the Northern General.
Safeguards in place Risk was assessed on the mother's age, body weight, blood test results and the length of pregnancy. But between 4 January and 24 May last year the PathLAN computer misinterpreted the results. Professor Davies said it was vital the NHS learned from the error and put in place safeguards to prevent a repeat of the blunder. She said: "It was very specifically related to the Millennium. "When it went to 2001 it (the computer) just didn't calculate the mother's age correctly. When that information was fed into the computer the calculated risk was wrong. It just demonstrates how careful you have to be at every stage in the system."
'Strange results' "They (the trust) were reassured, they thought everything was fine. When the results started to look strange they just thought it was a different mixture of women coming through, rather than the computer software. This was a simple error that shouldn't have happened."
Hospital managers have changed procedures "I have every sympathy with the families involved. The NHS is a learning organisation and they will have to learn from it." The Northern General Hospital apologised to the families affected by the computer error. Andrew Cash, chief executive of Sheffield Teaching Hospitals NHS Trust, which manages the hospital, said: "We would like to say how very sorry we are to the women and their families who were affected by the error. "They were put in the unacceptable position of being given reassurance by the test and then having that taken away from them. "The recommendations in the report and the steps we are taking will ensure to the greatest possible extent that errors of this nature cannot happen again.
'Changes made' "We've already made changes to the Down's Syndrome screening service we offer and will build on this progress through implementation of the report's recommendations." The report says consideration should be given to the replacement of PathLAN throughout the NHS. It also recommends that consideration be given to the creation of a National Downs Risk Calculation Reference Application against which software can be tested.
Many of those affected were over 35 and were patients at nine hospitals in South Yorkshire, Lincolnshire and Nottinghamshire. The computer software error, which was later rectified, occurred between January and May last year.
-- Rich Marsh (firstname.lastname@example.org), October 02, 2001