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 (more…)

More Samsung ‘we try harder’ telehealth moves

Is Samsung playing Avis “We try harder®” to Apple’s Hertz?

Samsung’s other, less noticed end-run in addition to the Simband reference hardware and SAMI ‘open ecosystem’  is an initiative creating a joint research center with the University of California, San Francisco (UCSF) called the Center for Digital Health Innovation (CDHI). It is being headed by Michael Blum, a medical doctor who is the UCSF assistant vice chancellor of informatics. From the statements made to The Atlantic, Dr Blum’s intent is to clinically validate the sensors and algorithms produced within the Samsung ecosystem. Already featured are four initial projects: CareWeb (a collaborative care platform built on Salesforce.com), Tidepool (infrastructure for diabetes apps), Health eHeart (clinical trial app on heart disease) and Trinity (‘precision team care’). On the frontier: ‘novel vital signs’ which he predicts will come out of the analysis of standard vital signs, “…new markers of health and wellness that come out of these large datasets.”  Is Samsung, rather than going head-to-head with Apple on Healthbook [TTA 22 Mar] is leapfrogging into something akin to Telehealth 2.0 or 3.0? Yet this Editor notes that we haven’t figured out, for the most part, the FBQs (Five Big Questions)* of 1.0….

* The Five Big Questions (FBQs)–who pays, how much, who’s looking at the data, who’s actioning it, how data is integrated into patient records.

Going Googly over Glass: reviews

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/12/3022534-inline-s-6-a-surgeons-review-of-google-glass-in-the-operating-room.jpg” thumb_width=”150″ /]Glass has been out long enough and used widely enough in the health/medical area to have some meaningful reviews. The hot area seems to be surgery, and having previewed this at the end of a minimally invasive hernia surgery during Heather Evans, MD’s talk at the NYeC Digital Health Conference [TTA 16 Nov; also her AAS article], this Editor knew more were to come. University of California-San Francisco formally received the first approval from the Institutional Review Board to use Glass during surgeries (iHealthBeat 27 Nov). Pierre Theodore, MD, a cardiothoracic surgeon at UCSF, prior to that point performed 10 to 15 surgeries with Glass assistance. From a longer article in Fast Company: “His conclusion so far: the technology is indeed useful in the operating room as an adjunct device in delivering necessary information, but it still has miles to go as a product.” Other drawbacks are its dependence on an optimal Wi-Fi signal which can be chancy in an OR, its weakness on voice commands, being able to easily scan X-rays during surgery, patient privacy and very importantly, sanitization. Completely hands-free operation is the surgeon’s goal. (Photo of Dr. Theodore courtesy of Fast Company)