An emergency room nurse described her frustrating experience trying to accurately document a dose of heparin, a blood thinner for patients with chest pain. “The doctor stated he wanted 4000 units bolus [all at once] and then a 1000 unit per hour infusion,” she wrote. “The order in Paragon stated 5000 units of heparin. I was given the option to decrease the dose, which I manually changed.
“However, I had to pick a reason why I decreased the dose. There was a drop-down box, and the only option was ‘Insulin decreased per protocol.’”
In the unregulated world of health IT, there's no pre-market evaluation or QC process to find little "glitches" like this that make it onto floors of live patients.
The drug was heparin, not insulin. What was she supposed to do? “I contacted the pharmacy and spoke to three different people, and the final response was, ‘snapshot the screen and give it to your manager.’ This was a nine-minute conversation.”
That's really not very helpful to the patient needing heparin urgently.
The manager finally advised her to select the given option for insulin, then separately document that heparin, not insulin, was given.
No future mistakes are possible due to this little glitch "workaround", right?
That’s nine extra minutes away from the bedside, just to document one medication—and to document it inaccurately, to boot. Multiply that times the many different tasks and patients a nurse juggles every day, and you start to see the problem.
I point out that this order would have taken exactly ten seconds with a pen and paper.
I hear stories like this - odd "glitches" and "gotchas" - from medical colleagues at least weekly, and sometimes daily.