Weekend Must Read: How an EHR in a teaching hospital gave a patient a 39X overdose

Weekend reading and a banquet for your consideration.

Though computers can and do improve patient safety in many ways, the case of Pablo Garcia vividly illustrates that, even in one of the world’s best hospitals, filled with well-trained, careful and caring doctors, nurses and pharmacists, technology can cause breathtaking errors.

This one began when a young physician went to an electronic health record and set a process in motion that never could have happened in the age of paper.

From The Overdose: Harm in a Wired Hospital by Robert Wachter, MD (Medium.com Backchannel), Part 1 of 4

The situation is a pediatric patient with a severe chronic illness, with multiple symptoms requiring multiple medications to control, admitted to University of California San Francisco (UCSF). The article is a case history of the chain of events, both technological and human, that led to an severe overdose of a routine antibiotic medication, which the patient had already been maintained on for years, nearly killing the child. You will see, with horror, how every check-and-balance failed in the prescribing and dispensing procedure, and why.

Dr Wachter is not only chief of the medical service and chief of the Division of Hospital Medicine at UCSF Medical Center, but also writes extensively on healthcare policy, safety and quality. He is no Luddite: he carefully outlines the nightmarish, error-prone paper prescribing system first so that the reader can contrast. UCSF and their doctors were not new to EHRs, nor was this a shakedown cruise; their first was GE Centricity starting in 2000 then the hospital moved to Epic in 2012.

Unintended consequences of designing away from error, alarms and the human factor…all here. Stay with it through his paralleling healthcare tech with airliner flight deck technology and human factors in part 4, including an interview with retired US Airways Captain Chesley Sullenberger, the ‘Miracle on the Hudson’ US Airways captain and aviation safety expert.

In Captain Sullenberger’s words, “…it (automation) changes the nature of the errors that are made, and it makes possible new kinds of errors.”

Additional reading (you’ll want to): Dr Wachter’s book from which this is excerpted:  The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (Amazon). The NY Times op-ed, Why Health Care Tech Is Still So Bad, which (in his words) is an abstract of the book. Dr Wachter’s blog, particularly the entries on the NYT article and the interview with Captain Sullenberger comparing cockpit automation to HIT in healthcare.

Big hat tip to ‘drrjv’ for his link to this article, referenced in comments on a recent Becker’s Hospital Review article included in our recent article on EHR concerns.

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