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The lead story in Monday's Chicago Tribune chronicled the death of Genesis Burkett, a baby boy administered a fatal overdose of intravenous sodium chloride at Advocate Lutheran General Hospital in Park Ridge, Ill., last October. The child reportedly had received more than 60 times the dosage a physician ordered.
Quoting Advocate Health Care's chief medical officer, Dr. Lee Sacks, the Tribune said an internal investigation at the hospital found that a pharmacy technician entered the wrong value when transcribing a handwritten order into a computer. "The problem could have been identified by automated alerts on the IV compounding machine, but those were not activated when the customized bag was prepared for the baby, according to the hospital. Asked why, Sacks cited ongoing litigation and declined to elaborate," the story said.
An attorney for the Burkett family also blamed a mislabeled IV bag. The family has sued Advocate, the largest healthcare provider in Illinois.
With its Cerner EMR, Lutheran General has reached stage 6 on the HIMSS Analytics EMR Adoption Model, the second-highest level. It had to have computerized physician order entry (CPOE) and clinical decision support in place to attain stage 4 and closed-loop medication administration for stage 5. But, according to the Tribune, this particular drug was prepared by an automated compounding system that was not connected to the main CPOE and pharmacy information systems.
Advocate has since added electronic alerts to its IV compounders and initiated other medication safety measures, the story said, but the incident has thrust the issue of EMR and electronic health record (EHR) safety back into the spotlight. "While many people think that EHR usability is focused solely on user satisfaction, there are other key factors, such as patient safety, that are impacted by the usability of an EHR. The means by which patient data is accessed and displayed in an EHR system will ultimately affect the decisions of healthcare providers and the potential for medical errors," Booz Allen Hamilton senior VP Kristine Martin Anderson, a consultant in health IT and data analytics, said in an e-mail interview.
Dr. Mark Frisse, professor of biomedical informatics at Vanderbilt University Medical Center's Center for Better Health in Nashville, Tenn., cautioned against placing too much blame on the technology itself. "If we take every one of these examples and use this as a witch hunt ... we'd be returning to the dark ages where errors don't get reported," said Frisse. "However tragic this is, it is an opportunity to improve the system."
He agreed that systems don't always communicate well with each other, but argued against using this as an excuse not to continue the shift toward digital healthcare. "In the paper-based world, the inability of humans to communicate with each other was far more severe," Frisse said.
In the past, a culture of secrecy kept many errors from being reported, according to Frisse, an internist with training in hematology and oncology. "Society has a simple choice," Frisse said. "We can take technology that is everyday saving lives and make it better, or we can return to the days when errors were more commonplace and were not reported ... I can assure you that that the latter course will lead to more deaths with less documentation."
Anderson said technology vendors, healthcare organizations, and policymakers all must work together to prevent the kinds of mistakes that killed baby Genesis. "EHR vendors must be provided with the guidance and the market incentives that will drive them to build specific data controls into their product related to top safety issues," the Booz Allen consultant said.
"Similarly, healthcare organizations must be provided with the guidance that they need to procure usable EHR systems and to understand the potential patient safety risks associated with product customization. Through this shared responsibility for EHR usability, we can minimize the risk of medical error and enhance the quality of patient care."
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