Friday, March 28, 2014
Now Here Is The Practicalities Of Just How Bad Health IT Can Actually Contribute To A Patient Death.
This awful story appeared a little while ago.
By Robert N. Charette
Posted 10 Mar 2014 | 20:36 GMT
The number of IT-related errors, ooftas, and deficiencies reported last week reverted back towards the mean from the previous week's overabundance. We start off this edition of IT Hiccups with a sad case of a child’s death in the UK. The tragedy is being attributed in part to the past effort to fully computerize the UK’s National Health Service.
According to the Bristol Post, a coroner in charge of the inquest into the death of Samuel Starr, aged three, indicated in a narrative verdict that, “Due to the failure of the [Royal United] hospital's outpatient booking system, there was a five month delay in Samuel being seen and receiving necessary treatment.” It is very rare for a coroner to criticize a hospital IT system so directly.
Samuel Starr was born with “complex congenital heart disease” in 2009. His parents were told at the time of his birth that Samuel would need several operations before he was five, and in fact, Samuel underwent an operation when he was nine months old. The Post reported that he made a good recovery, and was due to have regular checkups and further treatment at the Pediatric Cardiac Clinic at the Royal United Hospital (RUH) in Bath. Samuel received a checkup in October 2010 and one in April 2011, at which time his parents were told by his doctor to schedule another in about nine months for a more extensive examination of his heart.
However, a new electronic health record system, called Cerner Millennium, was being installed in 2011 at the hospital as part of the NHS’s National Program for IT (NPfIT), which was shortly thereafter cancelled. Though the main program was cancelled, certain elements, such as its national Choose and Book system for patient scheduling, remained. (Hospitals, like at Royal United, that were already installing electronic health record systems were given the go-ahead to proceed if they wished).
According to the Daily Mirror, “glitches” in the Royal United patient booking system caused Samuel not to receive his scheduled appointment with heart specialists as required, despite pleas for an appointment by his parents and a primary care specialist. The Mirror stated that medical secretary for Samuel's doctor insisted that she had taken down the appointment details and forwarded them on to a dedicated appointments team, but they were apparently not logged in. “While Samuel's medical records had been created on the new Millennium computer program, no appointments had been transferred across [from the old scheduling system],” the Mirror explained.
By the time Samuel was eventually seen, his heart condition had taken a turn for the worse, and he required immediate surgery. Unfortunately, the child died after enduring a series of cardiac arrests a few weeks after his surgery.
The rest of the story is found here - along with some other mess-ups.
This is a sad story which shows just how there can be consequences if great care is not taken to ensure IT that is involved in patient care is not looked at a whole and that seamless end to end operation is assured. Also important is to carefully ensure that issues that emerge with respect to use of systems and IT are appropriately escalated and remedied.
This really feels like a glitch that should have been caught and it is sad that it apparently was not.
Posted by Dr David More MB PhD FACHI at Friday, March 28, 2014