healthy4u: medication error

EHR Story for Mother's Day 2014: Even The Formerly Simple Act Of Giving IV Fluids in ICU's Can Kill Babies. But's Let's Be Objective and Happy!

<div style="text-align: center;">[Note to the humorless:  this post is satirical and sardonic to make a very serious point about the perversity of downplaying/ignoring health IT risks, issues too often ignored by those who know better.  If you don't like satire, don't read it.] </div> I've been critiqued for posting in too gloomy a manner for some's taste, even those who like me are in the Medical Informatics field.  For example, in the Feb. 2013 Kaiser Health News article "Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes" at <a href="http://www.kaiserhealthnews.org/stories/2013/february/18/scot-silverstein-health-information-technology.aspx">http://www.kaiserhealthnews.org/stories/2013/february/18/scot-silverstein-health-information-technology.aspx</a>: <blockquote class="tr_bq">... Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn’t comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.</blockquote> Of course, if a close relative of these unnamed "many" were killed by, say, a drunk driver (something this unobjective group of mothers takes seriously:  <a href="http://www.madd.org/">http://www.madd.org/</a>), or if their child were abducted and decapitated (<a href="http://en.wikipedia.org/wiki/Murder_of_Adam_Walsh">http://en.wikipedia.org/wiki/Murder_of_Adam_Walsh</a>), or if something like this event (<a href="https://www.youtube.com/watch?v=55XJivhjB4U">https://www.youtube.com/watch?v=55XJivhjB4U</a>) happened, their response would surely be "oh well, stuff happens, let's all be 'objective', not 'personalize' things, not advocate with our personal stories, and above all, be happy!    <div class="separator" style="clear: both; text-align: center;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgz2Sc_Ep0eHVvzgNTK2PPqnYAKho1OUX3pg4Y8MMphHPtZ3nKt71CbjXSeq3PvKwzIPeU6vw8CW5WskPOtYVfQe2bYtIbV9DW-T1KShF-n_EMiMdFwTzT_HR-m58p4oHUhj1JuMVtKbhpg/s1600/smiley.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgz2Sc_Ep0eHVvzgNTK2PPqnYAKho1OUX3pg4Y8MMphHPtZ3nKt71CbjXSeq3PvKwzIPeU6vw8CW5WskPOtYVfQe2bYtIbV9DW-T1KShF-n_EMiMdFwTzT_HR-m58p4oHUhj1JuMVtKbhpg/s1600/smiley.jpg" /></a></div> I really do admire the unnamed "many" for their ability to detach, so am presenting the following story of "anecdotal" patient harm to a child in a pediatric ICU in the spirit of happiness, joy, and Mother's Day love! <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1nVbtntosQYTim-y3sdm6vTMvInD2jgP1ZlsrcxGevCVfigNMgPvzd8HUqh4qznVDYUP4YCPDpMpgcXg4RaT3XCIO4RjdDTdAPL_aExrCYK3A5ePMQZwv8cEk2lGgbZspCOR74YLbtkRd/s1600/vintage_housewife_cook.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1nVbtntosQYTim-y3sdm6vTMvInD2jgP1ZlsrcxGevCVfigNMgPvzd8HUqh4qznVDYUP4YCPDpMpgcXg4RaT3XCIO4RjdDTdAPL_aExrCYK3A5ePMQZwv8cEk2lGgbZspCOR74YLbtkRd/s1600/vintage_housewife_cook.jpg" width="175" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBVdvcXC2vRHlGd1UhzTgr2F7Ut7bWo3S_ppYkE1Ji-F5AMjm1uHvJx2apITS82nBcYMZDHEVDUwW7IUVMpLLc22Y-7Q318dPGia2NwyjsGojNmzNO4Hpsovvd2f9c42UgYEeaEuEq755A/s1600/smiley1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"> </a></div> Here's the event we should all be happy about, reported via FDA - I note the FDA's said these devices are not "sufficiently risky" to warrant a high level of their attention even though they secretly admitted in an internal memo that there's no way to really know te true level of risk and harm (<a href="http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html">http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html</a>), so clearly they're all a really jolly bunch: <blockquote class="tr_bq"><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?id=117690">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?id=117690</a> FDA MedSun report Type of device: medical device data system Device brand name: PowerChart Device manufacturer's name: Cerner Corporation Date of this report: (mm/dd/yyyy) 03/04/2014 Describe the event or problem:     Medication Error. This event was related to Health Information Technology. Specifically, the manner in which the system processed an order for free water replacement. Order was intended to be 20ml/hr for 6 hours for a total of 120ml. It was a 1000 ml bag so first they put 20ml/hr which would have defaulted the infuse over time to 50 hrs. They tried to change the infuse over to 6 hours which then changes the ml/hr rate to 167 ml/hr. They did not notice this had changed. </blockquote> Well, that's WONDERFUL!!  :-)  that the computer recalculates the flow rate for them when they change the infusion time, by paternalistically assuming that's what they wanted to do - change the RATE of infusion - when what they actually did is manually change the TIME (duration) of infusion.  How LOVELY of some programmer to have given them this FANTASTIC convenience!! <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8yEnZHeor2UZZlhUf4qKrE_4fxFfxrQna0eHhEQagUgU-_a9j1wpRZEfLCAMhkhyphenhyphenOsXIplxq3wLZU4cE3m0rrvjUniE-RugNfZbwUtYsoZXALSsI9k4Grh7jfb78Uc0hHnW_Eh6NGrjDg/s1600/behappy.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8yEnZHeor2UZZlhUf4qKrE_4fxFfxrQna0eHhEQagUgU-_a9j1wpRZEfLCAMhkhyphenhyphenOsXIplxq3wLZU4cE3m0rrvjUniE-RugNfZbwUtYsoZXALSsI9k4Grh7jfb78Uc0hHnW_Eh6NGrjDg/s1600/behappy.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Aren't computers wonderful!!!</td></tr></tbody></table> Even the following should not be cause for ardent technophiles to wipe the smile from their downside-ignoring faces!! <blockquote class="tr_bq">... They did not realize that they needed to go into details tab to show the time frame so the patient got 167ml/hr instead of 20ml/hr for 6 hours. </blockquote> How obvious!!!  Every doctor, nurse, medical student and janitor knows from time immemorial knows you have to go into the detail tab to show the time frame!  (Smile) <blockquote class="tr_bq">... Order was verified by pharmacy and administered at that rate via peripheral IV. After approximately 1L of fluid had infused, patient showed seizure activity.  PICU (pediatric ICU) team called to bedside. Treatment provided for seizures and critical sodium and potassium. </blockquote> Awww ...  some seizures and critical sodium and potassium levels in the PICU.  Awww.....too bad!!!  We should be happy anyway!  For if this child died...the sacrifice would have been WORTH IT for the betterment of electronic medical records worldwide, and the parents no doubt would be flattered and joyous about their contribution to computing science.  After all, how better to figure out how to make this technology work?? After all, it takes a few broken eggs to make an omelette, and a few bumps in the road (like grave mounds) should be of little concern. Because, remember ... w.e. c.a.r.e! <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyOy_d372Rp11w3A5pCQBf6qnkp-yS-f-doYNL_pYtAkTMY8Rzj24CbQOHIUMcYdrEvM8d38R1Y1DKCwpakFqeoc3ZHv67S5PpRuDwz-sq_fpE3DstFh_OLkzQGej3MaZbuWAuHH8BQPTe/s1600/words+that+work.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyOy_d372Rp11w3A5pCQBf6qnkp-yS-f-doYNL_pYtAkTMY8Rzj24CbQOHIUMcYdrEvM8d38R1Y1DKCwpakFqeoc3ZHv67S5PpRuDwz-sq_fpE3DstFh_OLkzQGej3MaZbuWAuHH8BQPTe/s1600/words+that+work.jpg" width="155" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">i c.a.r.e!!!!  As at U. Arizona Healthcare System, let's only use Happy Words with our patients about these systems! (click to enlarge, see <a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html</a> )</td></tr></tbody></table> Further, we should use only Words That Work to describe the wonders of these systems in their current state!!! <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgAtZ_SQ0RVtQt8McdXxf2OEPLie5Sk706vuqci5i-jIWHJpJS0iZa7s09yVFO41Bbwq4GvWWpzRRMw9AxeldgzFHxb18eCHSaTtZn73KyFqrypUR2XyQHFf_UhSsRPXw0U5t4WQSm3fFv/s1600/flowers.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgAtZ_SQ0RVtQt8McdXxf2OEPLie5Sk706vuqci5i-jIWHJpJS0iZa7s09yVFO41Bbwq4GvWWpzRRMw9AxeldgzFHxb18eCHSaTtZn73KyFqrypUR2XyQHFf_UhSsRPXw0U5t4WQSm3fFv/s1600/flowers.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Some flowers from Cerner CEO Patterson to momma to make up for her little baby having seizures and critically deranged potassium and sodium levels from those big, bad doctors' EHR mistake!</td></tr></tbody></table> <blockquote class="tr_bq">... The Cerner powerchart software system has functionality for continuous medications/fluid ordering that does not prevent "user error." </blockquote> Ut oh ... Looks like I'm going to have to be a sourpuss for just a moment and re-introduce the nasty, ill-tempered, non-objective idea of what the dastardly National Institute of Technology and Standards (NIST) calls "use error" (as opposed to "user error", A.K.A. "Blame the User",  <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a>): <blockquote class="tr_bq">... The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized. [3] “Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions - ed.], misuse of color-coding conventions [see below], omission of information, etc. </blockquote> Awwwwww....aren't I just mean and non-objective? <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8h7Y65reXdJO632szxyY2e3UhlY3P8xr5VhF4vPIz_8cTZXCU_8L4DKIks0v0LLVJwWrKKd9BzQKa7OJpJv5NXGJkqpvjMd7xKU1mjfEaUD6F7MkhesXaq0Gw_4wHcv1DTduyxsr3atPO/s1600/frown.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="165" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8h7Y65reXdJO632szxyY2e3UhlY3P8xr5VhF4vPIz_8cTZXCU_8L4DKIks0v0LLVJwWrKKd9BzQKa7OJpJv5NXGJkqpvjMd7xKU1mjfEaUD6F7MkhesXaq0Gw_4wHcv1DTduyxsr3atPO/s1600/frown.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"> </td></tr></tbody></table> That mean doctor Silverstein's just not happy and objective!!  Bad, bad, bad man! <blockquote class="tr_bq">... When the provider orders the fluid, example is D5W, the screen opens to a "continuous details" ordering window. Within the screen, the ordering provider is presented with a preselected bag volume and type of fluid with a brownish background. They have the ability to modify bag volume but it was made this color to discourage that change by Cerner. </blockquote> Golly gee!  There's something to be happy about once again!  Brown, the universally-understood color, in any language, means "Warning, do not change this value, it could kill someone!!!" See how GOOD this technology really is!!!  Why use alerts and confirmation dialogs when a mere COLOR like brown suffices!! <blockquote class="tr_bq"> ... The rate and "infuse over" fields are a yellow color to show that they need to be completed. The intent [of the programmer, clearly an expert in human-computer interaction and communication by color and smoke signals - ed.] is for an ongoing continuous fluid and not to limit the time. </blockquote> Golly Gee Times Two!  Yellow, the absolutely universal color for "Warning, you need to complete this to prevent killing someone!"   <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB07i36jmKHcewYx3Gz9u_Dn1b_sU77r5meRSlFySibvF182tqSVyjtTqOuue6t6pDz1RWP6W580szZKrms1eEmRSb_RIpzZGgVfKNduKoAx7uHGW2dKivEC1nq0UCSXHoKm4H1Q_gHPfw/s1600/yellow-light.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB07i36jmKHcewYx3Gz9u_Dn1b_sU77r5meRSlFySibvF182tqSVyjtTqOuue6t6pDz1RWP6W580szZKrms1eEmRSb_RIpzZGgVfKNduKoAx7uHGW2dKivEC1nq0UCSXHoKm4H1Q_gHPfw/s1600/yellow-light.jpeg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Yellow!  Don't you just think every time you see this color that "warning, you need to complete data entry to avoid killing someone?  Who needs WORDS?</td></tr></tbody></table> It's all so CLEAR!!!! <blockquote class="tr_bq">... Providers can misinterpret this field to mean the length of time they want the order to infuse over, when the system intent for that field is to be the system-calculated length of time until the next bag supply will need to be sent to maintain the continuous infusion.  </blockquote> See how simple!!!!   Isn't it OBVIOUS!!!! <blockquote class="tr_bq"> The completed fields turn white. Cerner does not have an intermittent fluid administration order [who the hell needs that, says Cerner and the hospital executives who bought this package for the PICU!! Never a need for that in ICU's!! - ed] so providers are expected to go to a second tab, the "details" tab, where they have the options for identifying the duration of the infusion in terms of # doses or time. If the provider does not have awareness of this intent and modifies the "infuse over" field from the "continuous details" tab, they may inadvertently order a higher rate than intended.</blockquote> Ha ha!  Those silly doctors can't even figure out a simple thing like that!!  What stooges they are!! <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT3rcoW8Gw85QLLLUqEtmVvyIqCGPmTDBoLqWmwLa5zC0a-4ORhr7iLkFrSZBeA02TCfVLzn5pqH7WxtywG0kyZt54ExddyyuDE_UjALynE545TJIgb5SaosZIC6vFUiC9jt6yhyphenhyphenPpqf5i/s1600/three-stooges.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="156" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT3rcoW8Gw85QLLLUqEtmVvyIqCGPmTDBoLqWmwLa5zC0a-4ORhr7iLkFrSZBeA02TCfVLzn5pqH7WxtywG0kyZt54ExddyyuDE_UjALynE545TJIgb5SaosZIC6vFUiC9jt6yhyphenhyphenPpqf5i/s1600/three-stooges.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">NYUK NYUK NYUK ... Hey Moe!!  Those silly doctors and nurses cannot understand the simple fact that Cerner does not have an intermittent fluid administration order so providers are expected to go to a second tab, the "details" tab, where they have the options for identifying the duration of the infusion in terms of # doses or time. If the provider does not have awareness of this intent and modifies the "infuse over" field from the "continuous details" tab, they may inadvertently order a higher rate than intended.  </td></tr></tbody></table> See how much FUN health IT problems can be?  After all, in this ANECDOTAL case, all that happened was: <blockquote class="tr_bq">The device(s) may have caused or contributed to: Potential for patient harm, Serious Injury </blockquote> But nobody died of this particular problem (that we know of), so this technology is SAFE!!!! <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNHrlprFiMwMg8w-uhH23RA1KLiJ7O5qDqdj547Mc40zYY4nDhmNEqZ_d5163YRafaQ34simadB6lLrldXAktiWpOZNGbn2kctTetmpIBNH6FhjjBEO7ZIqwQm9Lgo68p7sjlS1Z5FofgT/s1600/Happy-Mothers-Day.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNHrlprFiMwMg8w-uhH23RA1KLiJ7O5qDqdj547Mc40zYY4nDhmNEqZ_d5163YRafaQ34simadB6lLrldXAktiWpOZNGbn2kctTetmpIBNH6FhjjBEO7ZIqwQm9Lgo68p7sjlS1Z5FofgT/s1600/Happy-Mothers-Day.png" width="320" /></a></div> Happy mother's day!!! -------------------- Additional not-so-funny thought:  depending on brown, yellow etc. instead of clear, written alerts/warnings, plus the fact that the system likely "knew" the weight of the child and should have alerted that the infusion of a liter was a very dangerous thing, reflect Bad Health IT on its face: <blockquote class="tr_bq">Bad Health IT ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </blockquote> Had I been a pre-marketing tester of this system working for FDA, those fluid-ordering characteristics would have been changed before the system would have been released to market. Oh, wait ... there is no premarketing testing process for health IT, and FDA, via advice from the FDASIA committees as in the linked FDA-related post above, writes that none is really needed. And who wants to damage TRUE INNOVATIONS like this - turning something that takes 5 seconds for a clinician to write, "D5W, 20 ml/hr x 6 hrs" (meaning dextrose 5% in water, 20 milliliters per hour for 6 hours) into a cryptic and muddled exercise with tabs, colors and numerous caveats - via regulation? -- SS

EHR Story for Mother's Day 2014: Even The Formerly Simple Act Of Giving IV Fluids in ICU's Can Kill Babies. But's Let's Be Objective and Happy!

[Note to the humorless: this post is satirical and sardonic to make a very serious point about the perversity of downplaying/ignoring health IT risks, issues too often ignored by those who know bet…

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09 May 2014

More "anecdotes" of health IT-related errors - System errors with Victoria's trouble-plagued HIT program caused more than 100 medication mix-ups at two Melbourne hospitals

There are those in the field of health IT who see every health IT-related mishap as an "anecdote" - the "<a href="http://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html">anecdotalists</a>" - and every "positive" study, no matter how weak, as "solid evidence" of the technology's beneficence and efficacy. See "Anecdotes and Medicine, We are Actually Talking About Two Different Things" at <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html</a> for more on the risk management/scientific method confusion it represents, from a clinician Down Under. More "anecdotes" from Down Under to make the anecdotalists' heads explode: <blockquote class="tr_bq"><a href="http://www.theage.com.au/victoria/computer-errors-blamed-for-medication-mixups-20131030-2wgzs.html">Computer errors blamed for medication mix-ups</a> The Age.com (Australia) October 30, 2013 Kate Hagan System errors with Victoria's trouble-plagued health technology program have caused more than 100 medication mix-ups at two Melbourne hospitals and need to be fixed urgently, the state's Auditor-General has found. ... Auditor-General John Doyle said problems at three hospitals were putting patients at risk of missing prescribed medications or receiving incorrect doses, in a report tabled in Parliament on Wednesday. </blockquote> [Note: the full government audit report is available at <a href="http://www.audit.vic.gov.au/reports_and_publications/latest_reports/2013-14/20131030-clinical-ict-systems.aspx">http://www.audit.vic.gov.au/reports_and_publications/latest_reports/2013-14/20131030-clinical-ict-systems.aspx</a> in fulltext and PDF.  Other risks besides medication errors were found.  The general problems it reports in the Victoria health IT program were written about here since 2004 and at my Drexel site since 1998 - poor planning and an inadequate understanding of system requirements, underestimated project scope, costs and time lines, as well as underestimations of the required clinical workflow redesign and change management efforts. More on this in a future post.] <blockquote class="tr_bq">Problems included HealthSMART recording patients as having being discharged when they had only moved within the hospital, and difficulties for doctors in recording complex medications in the system. Mr Doyle said a voluminous medication list meant doctors sometimes [picked whatever was easy -ed.] [and] printed out an incorrect prescription and then changed it manually, resulting in an inaccurate electronic record.  </blockquote> The doctors likely did this on order to be able to actually see patients and not fiddle with the computer incessantly. <blockquote class="tr_bq">He said incident reports at two hospitals had recorded "more than 100 reported incidents of missed or nearly missed medication, as well as medicines being administered at a higher dose than prescribed". They included incidents in which "pain relief, antibiotics and other medication were given twice or not at all due to this issue".</blockquote> That's a good way to injure or kill people.  Trust me, <a href="http://hcrenewal.blogspot.com/2011/06/my-mother-passed-away.html">I know</a> - personally. <blockquote class="tr_bq">... He said hospitals had put manual measures in place to mitigate risks but they were not fail-safe, created inefficiencies and did not provide a long-term solution.</blockquote> Workarounds always introduce new risk.  I also remind that one should never need to work around something that's not in your way. <blockquote class="tr_bq">"As a result, there is continuing potential risk to patient safety that needs to be closely monitored by both [the Victorian Health Department] and the relevant health services," he said.</blockquote> At least in Australia they state the truth, clearly, as opposed to Americans, who make excuses (see for example my Sept. 16, 2013 post "An Open Letter to David Bates, MD, Chair, ONC FDASIA Health IT Policy Committee on Recommendations Against Premarket Testing and Validation of Health IT" at <a href="http://hcrenewal.blogspot.com/2013/09/an-open-letter-to-david-bates-md-chair.html">http://hcrenewal.blogspot.com/2013/09/an-open-letter-to-david-bates-md-chair.html</a>). At least there's this: <blockquote class="tr_bq">Health Minister David Davis said this week that Victoria had "learnt the lessons from the flawed HealthSMART program" and promised that hospitals and health professionals would have more say on future projects, which would be based on sound business cases.</blockquote> In my view we don't need non-clinician hospital management (including and especially the business computing personnel) to "have more say", we need the health professionals to predominantly have that role. For those who've never completed medical/nursing school nor completed a medical internship/residency/practice, only the exceptional can comprehend the true complexities of healthcare and health IT to support it [see note 1].  As observed in "Hiding in plain sight: What Koppel et al. tell us about healthcare IT", Nemeth & Cook, Journal of Biomedical Informatics 38 (2005) 262–263 at <a href="http://www.wapatientsafety.org/downloads/article-8.pdf">http://www.wapatientsafety.org/downloads/article-8.pdf</a>: <blockquote class="tr_bq">... On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occasional visitors to this setting see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it. The technical work that clinicians perform is hiding in plain sight. Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it. </blockquote> Unfortunately, the truly exceptional in hospital management are few and far between, despite the Lake Woebegon stories seen about them in their P.R. (See Roy Poses' post "Where No Hospital CEOs are Below Average" at <a href="http://hcrenewal.blogspot.com/2010/07/where-no-hospital-ceos-are-below.html">http://hcrenewal.blogspot.com/2010/07/where-no-hospital-ceos-are-below.html</a>.) It's becoming clearer the "anecdotalists" were quite wrong about health IT and its propensity to cause or contribute to medical error, especially when done poorly, i.e., is bad health IT which is all too common.  I attribute this to conflict of interest and fairy tale views about IT. From my <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">teaching site</a>: <blockquote class="tr_bq">Good Health IT ("GHIT") provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. Bad Health IT ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </blockquote> -- SS [1] A corollary is as seen in a comment By Bruce Landes MD <a href="http://healthblog.ncpa.org/the-tyranny-of-electronic-systems/comment-page-1/#comment-212802">here</a> in what he calls the Landes EHR rule: "The enthusiasm for EHRs increases with the square of the distance from actual medical practice."

More "anecdotes" of health IT-related errors - System errors with Victoria's trouble-plagued HIT program caused more than 100 medication mix-ups at two Melbourne hospitals

There are those in the field of health IT who see every health IT-related mishap as an "anecdote" - the "anecdotalists" - and every "positive" study, no matter how weak, as "solid evidence" of the tec…

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31 Oct 2013

JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems" (<a href="http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full" target="_blank">link to fulltext</a>) by David C Radley, Melanie R Wasserman, Lauren EW Olsho, Sarah J Shoemaker, Mark D Spranca and Bethany Bradshaw. The authors performed a meta-analysis of the literature on Computerized Practitioner Order Entry (CPOE) systems in inpatient settings and concluded: <blockquote class="tr_bq">"Processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (or in  a range of 41% to 55% with ninety five percent confidence).  Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, or ∼17.4 million medication errors averted in the USA in one year." </blockquote> It is important to know the potential benefits of CPOE, as the government has been pushing this technology since the foundation of the <a href="http://www.healthit.gov/newsroom/about-onc" target="_blank">Office of the National Coordinator</a> (for health IT) within HHS since 2004.  Indeed, reimbursement penalties on Medicare will start in 2015 for non-adopters of government <a href="http://hcrenewal.blogspot.com/2010/03/on-oncs-proposed-establishment-of.html" target="_blank">certified</a> health IT. It is especially important to get to the truth about CPOE specifically, and health IT in general, in terms of risks, benefits, return on investment, improvements, and alternatives. Not long before this new JAMIA article appeared, an active study of EHR problems with voluntary reporting by members of the <a href="https://www.ecri.org/Pages/default.aspx" target="_blank">ECRI Institute's</a> Patient Safety Organization (PSO) <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">produced some concerning data</a>.  Namely, that over a 9-week period starting April 16, 2012, and ending June 19, 2012, 171 health information technology-related problems were reported from just 36 healthcare facilities, primarily hospitals. Eight of the incidents reported involved patient harm, and three may have contributed to patient deaths. Obviously, extrapolating those number to:  1)  a much higher number of hospitals, of which the U.S. alone has <a href="http://www.aha.org/research/rc/stat-studies/fast-facts.shtml" target="_blank">approximately 5,700</a> plus other facilities such as long-term care, and private physician offices; 2)  over a full year, not just 9 weeks;  3) accounting for the perhaps 5% voluntary reporting level (per Koppel) of issues such as medication errors; 4) plus accounting for (per FDA) the issue of lack of recognition of IT as contributing to medical incidents (this list is not all-inclusive) - the results are of concern. Thus, work such as in this new JAMIA article on CPOE is important.  The article can be downloaded in its entirety as of this writing from the link above.  The article describes a methodology that is quite complex, and obviously a great deal of time and effort was put into it.  It appears to be a valiant effort to get us one step closer to the truth.  This should be applauded. I was impressed on first reading of this literature meta-analysis and its statistical calculations. (Actually I needed to read it several times to fully grasp the methodologies involved.) The question arose in my mind, however: can this article's conclusions be true, and the ECRI PSO Deep Dive study be true, at the same time? Prior to going into an analysis and perhaps detailed critique of the methodology, and knowing the difficulties and contradictions the literature on this topic presents, I decided first to look at the source articles selected from the literature for inclusion in the JAMIA meta-analysis. In doing so, issues became apparent that shed light on the difficulties of meta-analyses on topics such as this. The only methodological issue I will mention at this time is that the study used a <a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">surrogate endpoint</a> - medication "error" rates before, and after, implementation of CPOE, rather than patient outcomes.  (The reason I put "error" in quotes is that, as the authors describe regarding study limitations, the exact definition varies from site to site and study to study.  They also acknowledge the limitations of using such an endpoint.)  Surrogate endpoints, however, may or may not reflect the actual information being sought regarding outcomes. As Roy Poses noted in a June 2008 post "<a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">Criticism of Surrogate Endpoints in Whose Interests?</a>": <blockquote class="tr_bq">... The problem with surrogate endpoints is that they are surrogates for the real thing. In many cases, a treatment may appear beneficial when measured by its affect on such endpoints, but not turn out to be beneficial when measured by its affect on real clinical outcomes, e.g., alleviation of symptoms, improvement of function, and prolongation of survival. There are many reasons why this may be the case. </blockquote>This weakens the present study as a basis for social re-engineering.  The authors responsibly acknowledge that via the statement in the conclusion that: <blockquote class="tr_bq">Future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery. </blockquote> When I reviewed the studies that were used for the meta-analysis, however, my enthusiasm for the results was diminished. The authors write: <blockquote class="tr_bq">Using the search terms of Ammenwerth et al, we updated the search using PubMed in February 2009, identifying 390 studies. Each was reviewed by two study authors (MRW and DCR). After applying the a priori inclusion/exclusion criteria, 10 studies were retained. [Listed in footnotes 10–19 - ed.]</blockquote><div id=":1cb"> Here are the 10 studies retained, as per footnotes #10 - 19.  Short excerpts (I am trying to keep this post relatively short) and my very brief comments about each of them are as follows.  Hyperlinks to the summaries and in some cases to fulltext are present in the online study itself at the full text link at top of this post. First, I note no randomized, controlled clinical trials, the gold standard of medical research.  That lack is not the fault of the authors; it is a general feature in the domain of healthcare information technology. That said:  Included study #1 (footnote 10): </div><div id=":1cb">Bates DW, Teich JM, et al, The impact of computerized physician order entry on medication error prevention. Brigham and Women's Hospital, J Am Med Inform Assoc 1999;6:313–21.</div><div id=":1cb"> <blockquote class="tr_bq">... During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001).  The study periods were as follows: baseline, 51 days, Oct-Nov 1992; period 1, 68 days, Oct-Dec 1993; period 2, 49 days, Nov-Dec 1995; and period 3, 52 days, Mar-Apr 1997. </blockquote> I note that this was a highly advanced setting with long-standing Medical Informatics expertise, performed by Medical Informatics experts of the highest caliber.  This was an ideal environment for the implementation of good health IT.  The results may thus not be generalizable to facilities without that level of experience.  </div><div id=":1cb"></div><div id=":1cb">Also, the study was a considerable number of years ago, some of it two decades ago.  While one might assume the technology has improved, the increased commercial sector involvement since the 1990's, and especially after the HITECH incentives of 2009, may be creating an increased occurrence of bad health IT, and/or implementation in facilities with far less (if any) informatics expertise. Thus, in my view the study's applicability to current times and to all medical organizations is not extremely strong.  Included study #2 (footnote 11): Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit, Pediatrics 2008;121:123–8 <blockquote class="tr_bq">... Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry.</blockquote> Here, 'n' is very small, and there is a finding that the CPOE had no effect on administration mistakes, prescribing problems, and pharmacy problems.  Thus, a ringing endorsement for national CPOE implementation this study is (unfortunately) not.  Included study #3 (footnote 12): The effect of computer-assisted prescription writing on emergency department prescription errors, Acad Emerg Med 2002;9:1168–75.<cite></cite> Without even a summary, my concern here is that ePrescribing and CPOE are different entities.   Inclusion of ePrescibing in a study of CPOE is not entirely without some risk of conflation of results of one with the other.  Included study #4 (footnote 13): Impact of computerized physician order entry on clinical practice in a newborn intensive care unit, J Perinatol. 2004 Feb;24(2):88-93. This article studies gentamicin dosing and turn around times and found that: <blockquote class="tr_bq">"...the accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. </blockquote> My comments are that a NICU is a specialized environment with a high ratio of clinicians/staff to patients.  Findings in such an environment again may not be generalizable.  Also, one should ask if complex CPOE systems are really needed for dosing calculations and turn around time improvements.  Simpler and cheaper human/technological solutions might have achieved similar or better results.  Thus, again, while not demeaning the results achieved by this study's interventions in 2004, I have my concerns that this study is not strong evidence of generalizability of even the CPOE surrogate measurement, namely decrease of med "errors."  Included study #5 (footnote 14): A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338:232–8. <blockquote class="tr_bq">We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. RESULTS: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P less than 0.01), excess drug dosages (87 vs. 405, P less than 0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P less than 0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P less than 0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P less than 0.02).  [Several other benefits omitted for brevity - they can be seen at the JAMIA footnote hyperlink -  ed.]</blockquote></div> My thoughts here are that, while the results were commendable, once again this study took place 15 years ago, and was in a high-staff-to-patient specialized ICU environment.  I also wonder if complex, expensive CPOE is needed to accomplish these tasks as opposed to, say, an online DSS and appropriate workflows and process.  Included study #6 (footnote 15): Impact of computerized prescriber order entry on medication errors at an acute tertiary care hospital. Hosp Pharm 2003;38:227–31. <blockquote class="tr_bq">The authors analyzed medication errors documented in a hospital's database of clinical interventions as a continuous quality improvement activity. They compared the number of errors reported prior to and after computerized prescriber order entry (CPOE) was implemented in the hospital. Results indicated that in the first 12 months of CPOE, overall medication errors were reduced by more than 40%, incomplete orders declined by more than 70%, and incorrect orders decreased by at least 45%. Illegible orders were virtually eliminated but the level of medication errors categorized by drug therapy problems remained significantly unchanged. The study underscores the positive impact of CPOE on medication safety and reemphasizes the need for proactive clinical interventions by pharmacists.</blockquote> This study appears reasonable for inclusion in a meta-analysis, although ideally there might have been accounting for possible influence of non-intervention (computer)-related pre-post interval changes.  The transition to CPOE, training, increased awareness, etc. can influence results, especially short term.  Included study #7 (footnote 16): Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med 2006;160:495–8. <blockquote class="tr_bq">Before-and-after study from 2001 to 2004. After CPOE deployment, daily chemotherapy orders were less likely to have improper dosing (relative risk [RR], 0.26; 95% confidence interval [CI], 0.11-0.61), incorrect dosing calculations (RR, 0.09; 95% CI, 0.03-0.34), missing cumulative dose calculations (RR, 0.32; 95% CI, 0.14-0.77), and incomplete nursing checklists (RR, 0.51; 95% CI, 0.33-0.80). There was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans (RR, 5.4; 95% CI, 3.1-9.5).</blockquote> Again, the results appear commendable.  However:  there was no difference in the likelihood of improper dosing on treatment plans, and worse, there was found a higher likelihood of not matching medication orders to treatment plans. In fact, this article was accompanied by a letter in response entitled "Primum non nocere", David Dickens, MD; Dianne Sinsabaugh, RPh; Brenda Winger, PharmD, Arch Pediatr Adolesc Med. 2006;160(11):1185-1186 (after some digging, text found at <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=486317" target="_blank">http://archpedi.jamanetwork.com/article.aspx?articleid=486317</a>): <blockquote class="tr_bq">Kim et al. demonstrated that in the practice of pediatric oncology, computerized physician order entry (CPOE) reduced improper dosing, missing cumulative doses, and incomplete nursing checklists.  In contrast to these benefits, however, CPOE also resulted in a 5-fold increase in “not matching medication orders to treatment plans.” Although little detail was provided on the nature of these medication order/treatment plan “mismatches,” it implies that chemotherapy ordered through CPOE deviated more often from intended protocol therapy as compared with paper-ordered chemotherapy. While CPOE ostensibly led to more precise chemotherapy dosing, it increased the risk of that chemotherapy being the wrong chemotherapy.</blockquote> The author did respond: "Mismatches between treatment plan and orders at point of therapy increased, but were intercepted and clarified at POC. [By people - ed.].  No incorrect meds were given. On its face, this is not an entirely dispositive proof of CPOE beneficence and raises significant concern that, sooner or later, a person might miss the discrepanc(ies) resulting in unintended adverse consequences.  Included study #8 (footnote 17): Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm 2007;64:1969–77. <blockquote class="tr_bq">This study took place at Lifespan health care system that includes Rhode Island Hospital (RIH), a private, 719-bed, not-for-profit, acute care hospital and academic medical center that has a pediatric division, the Hasbro Children’s Hospital; and The Miriam Hospital (TMH), a 247-bed, not-for-profit, acute care general hospital. Methods. The integrated systems selected for implementation included computerized physician order entry, pharmacy and laboratory information systems, clinical decision-support systems (CDSSs), electronic drug dispensing systems (EDDSs), and a bar-code point-of-care medication administration system. The indicators for CPOE with inherent CDSSs demonstrated a significant effect of this functionality on reducing prescribing error rates for three of the four indicators measured: drug allergy detection, excessive dose, and incomplete or unclear order. The fourth indicator measured, therapeutic duplication, did not show a significant effect on prescribing error rates. For the rules engine software CDSS, the colchicine indicator did not show a statistically significant effect on prescribing error rate, but a significant decrease in prescribing errors related to metformin use in renal insufficiency was observed after implementation of the rules engine software and integration with CPOE. </blockquote> Again, these are commendable results, but on its face the technologies involved went far beyond just CPOE, and the results were not uniform.  The actual reduction figures for seven categories were mostly in 50% range, one at 86% (allergy), but the duplicates issue at 8%, not felt statistically significant. Of more concern, there was this in the news in 2011.  A software bug at this organization led to thousands and perhaps tens of thousands of prescription errors that could have (and without definite proof, despite organization denials I would be concerned did) led to injury and death.  I wrote about the malfunction at <a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html</a>.  The bug was not discovered for about a year. Other organizations, especially those new to CPOE and/or health IT, face similar risks. Again, this is not a caveat-free endorsement of national CPOE rollout in 2013. Included study #9 (footnote 18): Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics 2008;121:e421–7. 627 pediatric admissions, with 12 672 medication orders written over 3234 patient-days.  The rate of non-intercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system, much less than previously reported for adults, and there was no change in the rate of injuries as a result of error. Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified. The issues of concern here are bolded and underlined above and need not be restated. Lastly: Included study #10 (footnote 19): Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. J Health Inf Manag 2006;20:46–53. <blockquote class="tr_bq">While a major objective of CPOE is to reduce medication errors, its introduction is a major system change that may result in unintended outcomes. Monitoring voluntarily-reported medication errors in a university setting was used to identify the impact of initial CPOE implementation on medical-surgical and intensive care units. A retrospective trend analysis was used to compare errors one year before and six months after implementation. Total error reports increased post-CPOE but the level of patient harm related to those errors decreased. Numerous modifications were made to the system and the implementation process. The study supports the notion that CPOE configuration and implementation influences the risk of medication errors. Implementation teams should incorporate monitoring medication errors into project plans and expect to make ongoing changes to continually support the design of a safer care delivery environment.</blockquote> This study appeared more a study reporting unintended outcomes than benefits. The total medication error reports increased post-CPOE but the level of patient harm related to those errors decreased.   (That decrease might have been due to human factors, or to serendipity, both of which cannot be expected to protect forever.) The reasons for the changes were described this way: <blockquote class="tr_bq">... Contributing causes. To assist in the development of safety interventions, contributing causes were identified for reported errors. The most common contributing cause was noncompliance to policy and procedure, identified in 40 percent of errors. For example, a previous order may not have been discontinued when a new dose change was entered, resulting in two active orders for the same medication with different dosages  The next most common contributing cause was computer entry errors, seen in 25 percent of mistakes. One example was if a medication order was placed on the wrong patient.  ["Use error" due to confusing user interfaces as recently defined by NIST - as opposed to "user error" - was likely to have contributed to at least some of these errors - ed.]  The next most common error was initial load errors (19 percent). During entry of all current medications on the day of activation, multiple category B errors were made. An example was a written order for sliding scale calcium gluconate “PRN,” which was entered into the CPOE system as “scheduled.” There were also computer design issues that contributed to 10 percent of errors. An example was when the pharmacist received two printouts for methylprednisolone 500 mg IV. He assumed it was a duplicate order, but when he reviewed the CPOE system, he saw that one order was for today and the other was for tomorrow. The dates for these orders were not visible on the order printout from the CPOE system. [This again seems to be 'use error' - ed.]</blockquote><div><div> <div><div> These issues can and will occur anywhere.  Once again, this is not entirely an article, either by itself or in a meta-analysis, that I find ideal in attempted proof of CPOE effectiveness and beneficence. In fact, after I reviewed this source, I noted that this study was eliminated from the inclusion set: <blockquote class="tr_bq">... Based on later expert reviewer feedback, we eliminated one additional study that solely used a voluntary reporting method for error detection, leaving nine studies for our final pooled analysis. </blockquote></div></div><div><div> It would probably not be hard to convince critical thinkers of the possibility this study was removed for reasons other than stated. In summary, while one should not and cannot expect perfection in the studies available in a meta-analysis, due to the difficulties in this domain the literature resources utilized were not ideal, and the surrogate endpoint also raises concern.  (I have not reviewed the entire corpus of potential literature myself.)  The authors conducted a difficult and rigorous study, but one cannot turn data "lead" (as in Pb) to gold (as in Au), no matter how hard one works or however good one's intentions are. The authors did note the limitations of the study, although their conclusion will likely be taken by the industry as a "full steam ahead" signal.   (I do note with some irony the proximity of this article's release to the soon-to-start massive <a href="http://www.himssconference.org/" target="_blank">HIMSS 2013 Annual Conference & Exhibition trade show</a>, March 3-7, 2013 in New Orleans, LA.)  While likely a coincidence, my concern is that CPOE vendors will be talking nonstop about these results. Thus, I agree with the author's conclusion (especially in view of the recent voluntary reporting-based ECRI PSO study) that "future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery." From a clinical perspective, "primum non nocere" and the avoidance of gambling billions of dollars applies, at least until a better understanding of the technology's risk/benefit ratio and how to improve it occurs. A fraction of those billions would pay for more robust, current studies on the scale needed to get closer to the truth, such as formal post-market, mandatory surveillance that measures not surrogate but primary variables - such as outcomes both positive and negative.  As noted by the authors, voluntary reporting has the least sensitivity towards uncovering error:  <blockquote class="tr_bq">... Reviewed studies used various medication error detection methods. Research suggests that the highest error rates are found through direct observation, followed by chart review, then automated surveillance, and voluntary reporting.  [Citations were made to papers by Flynn and Jha regarding these points - ed.] </blockquote> Formal studies are essential from the basis of medical (e.g., safety and public health), business (e.g., ROI and liability), and social policy perspectives (e.g., are we spending the billions of dollars this technology costs wisely). -- SS Addendum:    I have often been the <a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">fire-breathing and </a><a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">über-skeptic iconoclast</a> on matters such as this.  However, I will allow a true international expert to take on that role this time, Dr. Richard Cook, who had a guest post here yesterday (<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">link</a>).  Dr. Cook's opinion on this JAMIA study (again, reproduced here with permission) was this: <blockquote class="tr_bq"><div>A meta-analysis of the literature on the nature of the universe in the mid 1500's would have concluded that the sun revolves around the earth. The data isn't fake, just worthless.  </div></blockquote> -- SS </div></div></div></div>

JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "Reduction in medication errors in hospitals due…

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02 Mar 2013

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology. The first case involved a medication error (from a 'miscommunication between doctors and nurses', an infusion pump snafu, and failure to perform obvious follow up labs;  if health IT was involved it would not surprise me).  The second case involved alarm fatigue. These amounts are interesting considering the age and condition of the patients. 1.  <a href="http://www.lubinandmeyer.com/cases/medication-error.html">http://www.lubinandmeyer.com/cases/medication-error.html</a> <blockquote class="tr_bq">Medication Error Lawsuit against MGH Settles for $1.25 Million The plaintiff’s decedent was a 76-year-old woman who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times too much medication which resulted in uncontrollable internal bleeding and her subsequent death. Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia.</blockquote> and 2.  <a href="http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html" target="_blank">http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html</a> <blockquote class="tr_bq">Mass. General Hospital 'alarm fatigue' lawsuit settled for $850,000 BOSTON (AP) — The family of an 89-year-old man who died at Massachusetts General Hospital when nurses did not respond to alarms on his cardiac monitor has settled its case against the hospital for $850,000.</blockquote> I see potential lessons for at least two healthcare stakeholders in these cases: Hospital executives:  bad technology is not your friend.  get it right before rolling it out, with robust, validated safeguards, to save lives - and to save your organizations from costly litigation and reputational damage. Clinicians:  bad technology is your enemy.  While hyper-vigilance is mentally exhausting, that's what's required to avoid the fate of the patients - and the clinicians - in the above cases. Reporting bad technology and making sure the problems are remediated promptly, not glossed over, is equally essential. Note: my interpretation is that both technology and people issues probably played a role in both these accidents, based on my own knowledge and experience, but that is of course a personal opinion.  -- SS

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology.The first case involved a medication error (from a 'miscommunication between doctors and nurses',…

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