Wednesday, April 8, 2015

How does a 16-year-old boy receive 38 times the normal dose of an antibiotic?

If you are a doctor, nurse, patient, or just someone interested in patient safety, you should read a five-part story called "The Overdose: Harm in a Wired Hospital" excerpted from a book "The Digital Doctor" by Dr. Robert Wachter.

Dr. Wachter and the hospital are to be commended for publicizing this incident so others may learn from it. The hospital staff, the patient, and his mother, also deserve credit for allowing their stories to be told.

A synopsis does not do justice to this well-written account of the boy's near-death experience in a top hospital in San Francisco. In short, he somehow received a massive overdose of the antibiotic Septra despite the presence of a sophisticated electronic medical record and multiple systems in place that were supposed to prevent such a thing from happening.

After the patient recovered from receiving 38½ pills when he should have been given only one, a root cause analysis found numerous faulty system issues such as an electronic ordering program that was overly complex, a nurse "floating" to an unfamiliar floor, a satellite pharmacy that was too busy and susceptible to distractions, "alert fatigue" among hospital staff, and a culture, like that of most hospitals, that may have discouraged questioning both authority and the almighty computer.

Dr. Wachter contrasted the error-prone way we used to order medications on paper, which he said could take up to 50 different steps before the medication got to the patient, with the electronic process which even uses a “smart” robot instead of a human to count out the number of pills to be dispensed.

But in this case, errors such as those caused by illegible handwriting, transcription errors, and the like were replaced with errors we never dreamed of.

Twenty years ago, a human pharmacist probably would have questioned the order as he was counting out 38½ pills of Septra to be given as a single dose. But the "smart" robot didn't bat an eye [robots don't have eyelids].

And most of the nurses of that era would have balked at giving any patient 38½ pills of a single drug at one time.

A French airliner crashed because the pilots didn’t know what to do when the plane’s computer malfunctioned. The author of the lengthy Vanity Fair piece about it said, “automation has made it more and more unlikely that ordinary airline pilots will ever have to face a raw crisis in flight—but also more and more unlikely that they will be able to cope with such a crisis if one arises.”

A brief article called “The case for dangerous roads and low-tech cars” (also from a book “The World Beyond Your Head: On Becoming an Individual in an Age of Distraction”) by Matthew B. Crawford, discusses the possibility that so-called safety advances in automobile design may lull drivers into a false sense of security.

New options such as automatic braking when a car ahead slows down or an alert warning about a car in your blind spot may isolate drivers too much. Crawford says, “The animating ideal seems to be that the driver should be a disembodied observer, moving through a world of objects that present themselves as though on a screen.”

On the subject of roads, he writes, “When roads look dangerous, people slow down and become more heedful” and says that some new roads deliberately built with “less safe” features yield fewer crashes.

Like pilots and drivers, are hospital personnel becoming less vigilant by trusting computers and automation too much?

15 comments:

Anonymous said...

Anonymous Europe: Wow.. You guys can prescribe pills to kids?? Here where I am they hardly swallow the syrups we try to give them.. Seriously: the whole problem lies in automatizing the handing out of medicaments to the public as well as badly organized and paperwork ridden hospitals. Where I am there are three pencil pushers for every doctor and guess what: We go on a ward round around 8 ( that is normal European ward round time) and they pass us and each has a steaming cup of tea in her hands.... The problem is, hospitals are full of idiotic, mindless regulations, which are decided by people who did not even finish college let alone medschool... One more great story for this: in OR a new anaesthesiologist told me the story that when in the upper region of the state two clinics merged, there were 30 burocrats at the merger and 3 doctors....If we let this constantly happen to us,we will be way worse off than badly written prescriptions get handed out...

Anonymous said...

The answer to your question, in my mind, is: Absolutely. There are portions of medicine that have been greatly enhanced by the use of computers, but there is an equal set of areas that have either not benefited or, as this article points out, seen the birth of only new problems. Not only has the delivery of medical care been affected by the profligate, unchecked dissemination of technology, but the training of and professional roles of physicians have also been affected. As one colleague once asked, "What are these young docs gonna do when the lights go out?" I dared not offer an answer.

The other day I had a nurse tell me that in the not-too-distant future, all physicians will be good for will be signing off on diagnoses and orders made and placed by nurses or mid-level providers augmented by AI in every field from radiology to surgery, and patients won't mind since they'll still technically have MDs in the background and their out-of-pocket costs will finally be controlled. Granted, I'm fairly certain she was a bit off, but the looming reality of physicians losing their place on the front line and being relegated to cramped offices in the background isn't a very pleasant one.

Skeptical Scalpel said...

I believe the ratio of administrators to doctors in the US is 10:1. I agree about the mindless rules in hospitals. I've blogged about that.

You may be right about the future roll of doctors. As I've said many times, I'm glad I'm retired. But I'm sad for the younger generations.

William Reichert said...

Some time ago, I was consulted on a patient because of excessive
urination. The patent was putting out 4 or 5 five liters a day and no- body knew why. I checked out all the usual suspects, DKA, hyperglycemia, diabetes insipitus,ect. and all the meds listed on the
med sheet that documented his care. No diuretics. Finally, at my wits end, I entered the ICU room and noticed a number of med bags , some full, some empty hanging there on the IV pole . I checked each and discovered a bag labeled "dopamine ', slowly dripping in. I went to the nurse and asked how long the patient had been on dopamine . She said "He's not on dopamine". I said "come with me" and I showed her that he was in fact getting low dose dopamine ( that behaves like a diuretic.)
He had been on it for 2 weeks unbeknownst to those "taking care" of him. The next day I got a call from the head of nursing informing me that it was not nursing's fault. Perhaps the IV team or the pharmacy was responsible. I agreed with her. I did not want to be accused of
being mean to the nurses.Anyway. according to the computer printout and the nursing notes he was NOT on dopamine..Maybe a relative snuck in and hung the drug .No one was faulted. . The problem resolved. No "root cause analysis was undertaken " Why bother?

Skeptical Scalpel said...

William, that's a fascinating story.I'd like to turn it into a separate blog post.

Les said...

Wow, what a scary read! I used to work as a pharmacy tech back in the '80s and would have also assumed, as the nurse had, that the 37 extra tablets were there because the pharmacy was out of the appropriate dose. I wish the author would have mentioned the occasional hospital/pharmacy tendency where patients and their families are belittled when someone complains, "Hey, that doesn't look right." or "This isn't what he usually takes." Patient's who complain are sometimes viewed as nuisances, no?

Anonymous said...

Anonymous Europe:You know this is just plain crazy...
What is more bothering me is how nursing handled you. And your reaction "I did not want to be accused of being mean to the nurses..." A patient gets iv dopamine from somewhere, you find the error, correct it, signal it, and then you are almost made guilty of not being nice to the nurses and you have to be afraid of such accusations... (and I am pretty sure you are a nice guy). Something is terribly wrong...

Skeptical Scalpel said...

Yes, patients who complain are often viewed as nuisances.

A doctor cannot be perceived as criticizing a nurse. Such a perception would be harshly viewed if the nurse complained to administration.

Anonymous said...

I can attest to the patients who complain (even rightfully, respectfully and politely) are crapped on. Its like we are expected to take it and I'm sorry but no. A graduate degree does not give any person the right to take my money, mess me up and then tell me to say thank you.

That includes nurses who do not give me the medication the doctor ordered. I've done a lot for those who help and those who make a mistake and fix it. I will not in any way tolerate an attitude about it or make it out to be my fault when it was plainly theirs. If they can't fix a problem, admit it and fix it, then you were not 'called' to medicine.

Skeptical Scalpel said...

Admitting you made a mistake is the first step toward maturity.

frankbill said...

I find that the mistakes that that many providers make is looking at EMR and assume that past providers have done every thing right.

Anonymous said...

Skep, I knew there was a reason I admired you. You are right. Admitting you made a mistake is the first step. Oddly enough, I have said when I've picked the wrong diagnosis in the EHR. Modeling behavior. :)

Frankbill you forgot the EHR could be wrong, and I've got parts of several EHR's. So what you see might not be what you get.

frankbill said...

I know EMR can be wrong There are things in mine that I never said but it is what the provider thinks I said.

Anonymous said...

Anonymous said...
I can attest to the patients who complain (even rightfully, respectfully and politely) are crapped on. Its like we are expected to take it and I'm sorry but no. A graduate degree does not give any person the right to take my money, mess me up and then tell me to say thank you.

That includes nurses who do not give me the medication the doctor ordered. I've done a lot for those who help and those who make a mistake and fix it. I will not in any way tolerate an attitude about it or make it out to be my fault when it was plainly theirs. If they can't fix a problem, admit it and fix it, then you were not 'called' to medicine.



PREACHHHHHHHHHHH

Anonymous said...

@William ...... story of America's life

Post a Comment