Monday, June 27, 2011

Babies' deaths spotlight safety risks linked to computerized systems

A new tragic case. (A second, earlier case of infant death was posted in March 2011 here).

See Baby's death spotlights safety risks linked to computerized systems by Judith Graham and Cynthia Dizikes in the Chicago Tribune.

A baby died at Advocate Lutheran General Hospital due to an intravenous solution containing a massive overdose of sodium chloride — more than 60 times the amount ordered by the physician. The authors write:

Although a series of other errors contributed to the tragedy, its origin — a piece of data entered inaccurately into a computer program — throws a spotlight on safety risks associated with medicine's advance into the information age, a trend being pushed aggressively under health reform.

One wonders if any type of alert was generated, and if not, why not.

What are hospitals getting for their tens to hundreds of millions of dollars they are throwing at clinical IT?

Technology can be a great blessing in medicine. I am alive and healthy in 2011 thanks to it. The medical condition referred to in the aforementioned letter was in fact cured as a result of advances in cardiac electrophysiology science, as here and here, pgs. 1 and 2).

However, technology cannot be applied cavalierly, lawlessly (per attorney Sharona Hoffman), experimentally, without regulation, and without informed patient consent as is often done in the world of HIT.

-- SS

Also see another case at my aforementioned March 2011 post "Thanks to the wonders of EHR, this premature baby went to the grave, prematurely" at this link, from an Oct. 2010 story in Virginia Lawyers Weekly ("Failures in care alleged after premature birth - $1,000,000 Settlement"). A PICC line was also involved.

-- SS

4 comments:

Live it or live with IT said...

The Supreme Court has stated that materiality is a fact-based inquiry; “[t]his is not to say that statistical significance (or the lack thereof) is irrelevant – only that it is not dispositive of every case.”

Anecdotes, especially those that portend failures, are very important. Every malpractice claim is at its core an anecdote.

InformaticsMD said...

"Anecdotes" are often roadkill on the experimental racetrack of health IT.

-- SS

Anonymous said...

When the child of an inside the beltway lawmaker is overdosed and killed from an EHR or electronic ordering gismo, there may be an interest in Congress to understand the deception and fraud playing out in its chambers.

InformaticsMD said...

Anonymous June 27, 2011 9:18:00 PM EDT wrote:

When the child of an inside the beltway lawmaker is overdosed and killed from an EHR or electronic ordering gismo, there may be an interest in Congress to understand the deception and fraud playing out in its chambers.

That would be the "cybernetic Libby Zion case" I have written about, that is probably inevitable.

-- SS