Cincinnati Children's Hospital: Shots in the Dark

By Deborah Gage Print this article 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

The error was simple. But a newborn's life hung in the balance. Baby J needed more potassium chloride, a type of salt that is vital to the proper functioning of the nervous system. Too many of these dissolved salts, also known as electrolytes, can kill.

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-rays—and 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 chloride—about 5 cubic centimeters (cc), equivalent to a sixth of an ounce—per 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" parts—brain 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:
  • Poorly coordinated systems. Last year, at the Veterans Affairs Hospital in Northport, N.Y., a nurse working off a system similar to the one in Cincinnati saw on a Web record that it was time to give a diabetic patient a dose of insulin. The system, however, only kept track of when the patient ingested medicines, not meals. The nurse wound up giving the patient insulin on an empty stomach, which sent him into hypoglycemic shock, a condition caused by low blood sugar that can result in a coma. It was a "near miss," according to Dr. Mark Graber, the hospital's chief of medical services.
  • Lost instructions. Vanderbilt University Medical Center once accidentally cancelled a patient's CT scan. The scan was scheduled during the patient's transfer from intensive to intermediate care. Hospital policy required that all orders be rewritten during a transfer, but that policy did not make sense with computers. When employees went through the laborious process of canceling each order for a treatment in intensive care and converting it to a new order in intermediate care, the CT scan order was not re-created. And there was no paper chart full of orders stuck under the patient's mattress to alert nurses or doctors that anything was amiss, says Bill Stead, the director of Vanderbilt's Informatics Center.
  • Extra time. At Los Angeles' Cedars-Sinai Medical Center in January 2003, management suspended use of a computer medication system after doctors complained of the time it took to enter orders into the system. The physicians, to their frustration, found it took 5 minutes or more to log in to a system, fill out the patient and medication data needed to complete a request, and log out.

    There is no indisputable data on the number of errors caused by information technology, or for that matter on how many total medical errors exist—even 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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    This article was originally published on 2004-08-01
    Senior Writer
    Based in Silicon Valley, Debbie was a founding member of Ziff Davis Media's Sm@rt Partner, where she developed investigative projects and wrote a column on start-ups. She has covered the high-tech industry since 1994 and has also worked for Minnesota Public Radio, covering state politics. She has written freelance op-ed pieces on public education for the San Jose Mercury News, and has also won several national awards for her work co-producing a documentary. She has a B.A. from Minnesota State University.

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