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…)