Friday, November 04, 2011

Lifespan (Rhode Island): Yet another health IT "glitch" affecting thousands - that, of course, caused no patient harm that they know of - yet

There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" here, here, here and at other posts which can be found by searching this blog on the banal term 'glitch'.

I note that when a clinician makes a mistake, it's called "malpractice."

When health IT causes errors that can injure or kill, it's commonly referred with the banal, now-standard euphemism for computing malpractice:

Presenting the latest healthcare IT "glitch", affecting thousands:

Computer glitch led patients to receive wrong meds
Senator calls for review of Lifespan (Providence, RI)
Updated: Thursday, 03 Nov 2011, 5:47 AM EDT
Published : Wednesday, 02 Nov 2011, 11:56 PM EDT
Reported by Steve Nielsen

PROVIDENCE, R.I. (WPRI) - Rhode Island State Senator Jamie Doyle says he is shocked to hear a Lifespan computer glitch caused thousands of patients to receive the wrong types of medication. [Appx. 2,000 across five Lifespan hospitals according to the Providence Journal, see below, and the WaPo - ed.]

Doyle is now calling for an independent review of all the hospitals Lifespan runs, and a review of the Rhode Island Department of Health.

The DOH is investigating after learning patients who were supposed to receive medications taken once a day instead received medications meant to be taken more than once per day.

Health IT, of course, is unregulated by FDA or anyone, and vetted for safety only so far as the seller wishes to spend money on such tasks - which cuts their margins.  Ultimately, debugging is on live patients.

[11/5/2011 note: As an anonymous commenter pointed out, the 2,000 or so errors at Lifespan should probably be multiplied by the number of organizations using the same software ---> "The entire country may have suffered 25,000-50,000 errors from this one glitch alone", the commenter astutely notes - ed.]

Of course, the customary "we did feel lucky today, and the gun was empty" disclaimer follows:

"Lifespan has not reported any adverse events or situations where patients required additional medications, but the information gathering and investigation is still ongoing," said DOH spokeswoman Annemarie Beardsworth.

In other words, there could have been adverse events, we just at the Dept. of Health don't know yet with certainty, because none have been reported yet.

In addition, some patients who were meant to get a medication with a coating did not receive a coating. The coating can help with stomach pains of other problems.

"I just don't feel comfortable right now with some of the things that are coming out of there," Doyle said, "I really don't want to point fingers in any direction. but what we need to do is we need answers." Senator Doyle wants to have the review started in the next two to three weeks.

Mr. Doyle, see my academic site on HIT failures here and an account of repercussions here from an EHR-related medication error.

Lifespan released the following statement Wednesday:

"Lifespan is actively contacting 2,000 patients affected by this issue to ensure they receive the correct form of their medications. So far, we have reached out to more than 90 percent of the patients, many of whom were already taking the correct medication."

Lifespan expects to finish contacting patients by Thursday.

It will be interesting to understand the nature of this particular "glitch" and who the software vendor is.

All it takes is a single "glitch" to seriously reduce a patient's lifespan.

Siemens software may be involved. See this mutually self promoting, marketing-style Siemens document "Newport Hospital - a Lifespan Partner - At the Forefront of EMR Adoption" (PDF), also cached here. (As an aside, one wonders if the hospital and/or its leadership received special financial or other "incentives" in allowing their name to be used in corporate promotions.)

Also, Siemens was a company that apparently did not listen to an internal informatics specialist physician's concerns that their health IT for critical care was endangering patients (link). They terminated the whistleblower.

Also see my Aug. 2009 post "Why Siemens Healthcare Fails" which I had emailed at the time to the Siemens Healthcare CEO Hermann Requardt.

-- SS

Nov. 4, 2011 addendum:

Felice Fryer of the Providence Journal sent me a link to the story of Nov. 3, 2011 she wrote with a few more details, here. Excerpts:

Flaw found in hospitals’ prescriptions
Some patients discharged from Lifespan hospitals got right drugs in wrong form due to software error

Some 2,000 patients of the Lifespan hospital group were discharged with incorrect prescriptions over the past 9 to 15 months because of a software glitch.

[It took a year or more to discover these mounting errors? This is beyond the "red flag" warning signs I used to write about. This is crossing the chasm into the territory of "asking for catastrophe" - ed.]

The prescriptions listed the right medications, but in the wrong form: people who were supposed to get time-release pills received prescriptions for short-acting ones.

The error affected dozens of generic medications for a variety
of conditions. Lifespan discovered the problem on Oct. 25 and had fixed the software by Friday, according to Dr. Mary Reich Cooper, Lifespan’s senior vice president and chief quality officer.

The hospitals have placed calls to nearly all the affected patients, although not all have
called back, Cooper said. Most patients reached had already obtained the correct medication because the error was noticed by someone at the hospital, or a pharmacist or doctor outside, she said. So far, Cooper said, there is no evidence that any
one was harmed.

But Dr. Michael D. Fine, state Health Department director, said that the incident is an example of how electronic medical records, which normally help reduce errors, can sometimes amplify them by quickly affecting large numbers of people.
“It’s the flip side of what has otherwise been a process that has improved accuracy and reliability,” he said.

[I don't notice mention of a "flip side" to health IT in the aforementioned glossy hospital/IT company marketing brochure - ed.]

The Health Department is investigating the incident. Fine also plans to examine whether the department should regulate the safety of electronic systems in health care.
[Readers of this blog know my opinion on that matter - ed.]

Asked whether he was worried there may be other as-yet-unrecognized software glitches, Fine said, “I’m reasonably concerned about the accuracy and integrity of electronic medical records.”
... The software in question is not in use at other hospitals in Rhode Island, and the software vendor, Siemens, is notifying hospitals elsewhere in the country, according to Cooper.

[In the interests of public health, I believe it incumbent on Siemens to make this "glitch" widely known not just to the hospitals but to the public in areas served by those hospitals, especially with the admission that "
the (RI) hospitals have placed calls to nearly all the affected patients, although not all have called back." To not do so reflects negligence in my opinion - ed.]

... The errors arose from the process known as “medication reconciliation,” in which the physician compares the medications a patient was taking before hospitalization with those prescribed during hospitalization, and ensures that the patient goes home with a correct set of prescriptions. The Lifespan hospitals recently adopted an electronic system for this process.

Doctors were correctly prescribing medication, and the prescriptions looked right on the computer screen, Cooper explained. But when printing out the prescription list, the software was cutting off a two-letter abbreviation that indicated certain medications should be in long-acting form or coated to protect the stomach.

[As at Case 9 from FDA's MAUDE database at the post "
Our Policy Is To Always Have Unabashed Faith In The Computer". Do these vendors robustly validate their products? The current errors, in fact, were only peripherally related to medication reconciliation. They were primarily related to computer errors impairing (sabotaging?) the clinicians. It would seem med recon now needs to include comparing what the doctor enters to what is output to the nurses and other healthcare personnel who provide written instructions to patients. Is such a task performable by healthcare personnel when the computer cannot be trusted? Further, do the doctrine of the "learned intermediary" and "hold vendor harmless" clauses seem appropriate here? - ed.]

... Cooper said the risk of harm from taking a short-acting medication instead of a long-acting one was “very, very minimal.”

[Cooper misses the point, and IMHO such nihilistic attitudes have no place in healthcare - ed.]

But Fine, the health director, said such mistakes “can be scary.” People taking medication for angina or high blood pressure would find their medication wearing off over the course of the day,
putting them at risk of heart attack or stroke, he said.

Medical errors that might seem innocuous or minor to health IT amateurs can prove catastrophic.  I've seen it happen, leading to injury and death.

-- SS


Anonymous said...

Brown University Medical School and Medical Center ought to be called out on this fiasco.

This is the tip of the iceberg.

Patients were injured there in wrong site surgery,but the confusion and cognitive dissonance caused by EMR and CPOE gibberish was exonerated (or never considered).

Anonymous said...

Some of the patients that did not respond to the notification calls of the hospital may be dead. How will they ever know?

Anonymous said...

The hospitals of Brown Medical School are listed at this link:

Wonder if the Dean will give a guest lecture on defective HIT devices?

Anonymous said...

Did these hospitals collect the dough from the Feds for achieving meaningful mistakes? Just wondering.

Anonymous said...

What is strifing about this is that it took at least 15 months before any one knew about it!!

This is an example of the error promoting features of these devices. If the computer prints it, it must be correct; resulting in nurses and others not questioning the directives that the computer generates.

The nurses and others may be wading through extensive computer generated billing and other mind numbing gibberish that they are cognitively disabled when reading the directives.

The equipment appears to be meaningfully dangerous,

How could the government (CMS) penalize doctors financiallly if they do not buy and use this crapola?

A worried nurse

Anonymous said...

During the process "medication reconciliation"?

That is supposed to reduce medication errors, not increase them.

I am literally shocked and depressed that do no wrong computers have defects that may result in death.

I believed Barack Obama who told us tha HIT was going to improve medical care and reduce errors.

The entire country may have suffered 25-50,000 errors from this one glitch alone.

Go figure. Will someone please send this report to Barack and his HIT zealots Sebelius, Berwick, Hamburg, Durbin, Biden, Mutacheshavi (ONC), Pilosi; but do not leave out the HIT promoting Republicans Boehner, Toomey, Ryan, Hatch, Rowsey, Kantor, Bachmann, Perry, Romney, and others who are of the same HIT kool aid drinking ilk.


Anonymous said...

Safety programs at Lifespan: a finger in the dike of EMRs. First, wrong site surgeries (5 of them); now 200 medication errors

Anonymous said...

Relevant lecture at Brown:

Dr. Fine (of DOH) and team ought to attend.

Anonymous said...

Sebelius, Berwick, Hamburg, Durbin, Biden, Mutacheshavi (ONC), Pelosi, Boehner, Toomey, Ryan, Hatch, Rowsey, Cantor, Bachmann, Perry, Romney -- can they truely comprehend the report and understand the implications? No.

Politicians and business people have no place in making decisions about healthcare simply because they do not understand the topic well enough.

This is THE problem, not A problem.

Occupy the ONC.

InformaticsMD said...

Anonymous November 8, 2011 10:14:00 AM EST said...

Sebelius, Berwick, Hamburg, Durbin, Biden, Mutacheshavi (ONC), Pelosi, Boehner, Toomey, Ryan, Hatch, Rowsey, Cantor, Bachmann, Perry, Romney -- can they truely comprehend the report and understand the implications? No.

Actually...I don't know about the others, but Rep. Bachmann can and does understand the issues. Trust me on that.

-- SS

Bill Savedoff said...

Another angle: I was surprised to see Siemens name pop up here but probably should not have been. Siemens is one of the largest multinationals to have been debarred by the World Bank for corruption related to work in Russia (