In the last few days our nurse noticed that when she had a patient's details on screen and used "print current details" option from the Database menu, she got an extra section with an INR reading which did not relate to the pt. The printout takes the format of 3 sections. The top section has pt details-Name, address, DOB, Tel, Indication, INR Range, Date started, Treatment Length, Comments. The middle section is Current Warfarin Dose (daily schedule). The bottom section is a list of the last 12 INRs with the most recent on top.

For one particular pt on 23rd April an extra section was printed between the top and middle sections "23/04/2009 INR: 2.0" then "Today's recommended Warfarin Dose-continue same", then "Review date- 4 weeks 21/5/09". In fact no INR had been taken that day for that pt- it was the previous day and the reading was 3.6, which did show correctly in the bottom section. The nurse was worried and decided to do another print out later in the day for the same pt. The same thing happened again but this time the first extra line read "23/04/2009 INR 2.8"

Then the nurse realised that the INRs showing in the extra section were the from the previous pt seen just before the printout was done. How can this happen? I have tried on the same pt and others this morning from my PC but the extra section does not appear so it is like a one-day aberation, but is extremely worrying. About a year ago we had a serious event where the printout for the pt just tested was for a completely different pt seen at our branch surgery a week earlier. Our server hard drive failed a few days later so we put it down to disk corruption. ALthough this event has not had any repercussions it is worrying how it can happen.

Dear James,
Thanks for your detailed explanation. Very useful.
There was a an error in a previous early version of v3.7 when a patient printout was giving the previous patient's INR.
This was resolved in the next version.
Can you tell me the nurses version . Go to top menu Help ->About RAT will show a screen with the version number.

Can I ask you to upgrade the nurses RAT to v3.8.
And obviously can I ask that she reports if this happens again.

I am currently retesting using the 'Print current details' and looking at the source code for the software to see if I can replicate this.

Kind regards
Colm Rafferty