Cincinnati Children's Hospital: Shots in the DarkBy Deborah Gage | Posted 2004-08-01 Print
Physicians at Cincinnati Children's Hospital figured if they picked the right technology and the right vendor, establishing an electronic means of ordering drugs and recording patient treatments would easily reduce mistakes and improve care. But there was
Near Baby J's bedside at Cincinnati Children's Hospital Medical Center sat a slim computer terminal that allowed the staff to consult the hospital's Integrating Clinical Information System (ICIS) for instructions. The system was designed to track a patient's vital signs and medication histories on a Web page, around the clock. It also allows clinicians to order simple things such as blood tests, but also morphine, X-raysand potassium chloride.
To make sure that the right amounts of medicine are applied, the clinicians are presented with standardized lists of treatments and medications known as "order sets.''
Baby J got the wrong order.
The infant was supposed to get a solution that contained a small amount of potassium chlorideabout 5 cubic centimeters (cc), equivalent to a sixth of an ounceper liter. But the underlying data written into the order set for this procedure was wrong. The code, entered somewhere along the line from a team of programmers and physicians, called for 5 cc for every 250 milliliters, a concentration four times higher than intended.
An overdose of potassium chloride can short-circuit the body's "electronic" partsbrain waves and the heart, for instance. Just a half-ounce, or 15 cc, of that chemical compound is used to still the heartbeat of a prisoner on Death Row in a capital-punishment state such as Missouri.
The doctor who clicked on the order set was unaware he was administering an overdose. Only the sharp eye of a critical-care nurse, who looked at the solution brought into the intensive care unit, stopped the more concentrated mix from entering Baby J's veins.
Incidents such as this are forcing Cincinnati Children's and other hospitals to confront the dark side of computerization: It's not a panacea for patient care.
Patient care information systems, which place drug orders and keep track of patient records and images, promise to cut medication order and dispensing errors, especially those that result from the mislabeling of lab tests or from a doctor's illegible handwritten prescription. Cincinnati Children's system has eliminated the potential for hundreds of such errors. But what goes unsaid is that these systems require significant customization, are difficult to network, and are costly, at a time when one of three health-care institutions is losing money. An order entry system alone can cost up to $15 million. And, once installed, there still are unanticipated errors and adversities, like the one confronted by Baby J.
Hospitals have the added burden of building record-keeping and order entry systems that never lose or corrupt files, nor send out inaccurate or incomplete orders. When something goes wrong in a financial or manufacturing system, says Dr. Neil Johnson, who has led many of Cincinnati Children's systems projects, "There's not a human being who's directly affected. They can have a small rate of mistakes or a small rate of bad outcomes. When we make one of those mistakes, there's not just a lawsuit on the other end, but a human suffering. Our product is a human being."
But despite the best intentions, computer systems have not eliminated mistakes at Cincinnati Children's or other health-care facilities. The problems include:
There is no indisputable data on the number of errors caused by information technology, or for that matter on how many total medical errors existeven though the National Academy of Sciences' Institute of Medicine estimated in 2003 that "tens, if not hundreds of thousands" of mistakes occur daily.
In an academic paper published in March, a team led by Joan Ash, an associate professor at Oregon Health & Science University, detailed problems caused by patient care information systems at several hospitals in the U.S., Australia and the Netherlands. Ash said she was able to trace many of the troubles with patient care information systems to two main problems: errors in communications and coordinating processes, and errors in entering and retrieving data.
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