In the august British Medical Journal of April, 21, 2007 an article entitled LESSON OF THE WEEK: Information technology cannot guarantee patient safety appeared. The article was by Saskia N de Wildt, Ron Verzijden, John N van den Anker, and Matthijs de Hoog and the reference is BMJ 2007; 334: 851-852. (doi: 10.1136/bmj.39104.625903.80)
The article provided commentary on the following case report:
“A 3 month old infant who arrived at the emergency department of a small regional hospital had clinical signs of meningococcal sepsis with petechiae, purpura, and shock. The infant was subsequently transferred to our paediatric intensive care unit. During transfer the patient was given infusions of dobutamine and noradrenaline by the transferring intensivist. The concentrations of 12 drugs that might be needed for infusion during transport had previously been calculated in the intensive care unit by the resident. This had been done by entering the patient’s weight into a preprogrammed PocketExcel sheet for a personal digital assistant (handheld computer).
When the patient arrived at the unit all running drugs were ordered using our electronic patient data management system (a bedside computer application). This system uses the patient’s weight and the desired infusion rate to calculate concentrations of solutions for infusion. However, the concentration of noradrenaline calculated was sevenfold lower than that calculated previously, so that the patient had received a sevenfold higher dose of this drug than intended for at least two hours.”
In simple terms what had happened was that a spreadsheet based drug dosage calculator had been found to have misled a tired resident at 4.00am in the morning. The reason this was possible was that a simple spreadsheet running on a hand held computer was used and the spreadsheet did not have functionality to ensure constants were not overwritten and the child’s weight was entered into the wrong column.
On the basis of this the article concludes – as indicated in the title – that “Information Technology Cannot Guarantee Patient Safety” I could equally validly conclude that amateur spreadsheet authors should not be permitted to program computing tools they did not fully understand or even that doctors should be compelled to use pencil and paper to calculate drug dosage regimens.
William T Stevenson, a Consultant Radiologist of the Royal Lancaster Infirmary LA1 4RP gets it oh so right in a letter to the editor stating:
“Pretty soon we can expect a Lesson of the Week emphasizing that it's a bad idea to remove the wrong kidney.
The point here is that if a bunch of zombies (presumably members of the group who believe that information from the Internet must be reliable, that walking along the street engrossed in a mobile phone is an activity worthy of a sentient being and that counselling and mentoring are good ideas) are permitted to entrust all responsibility for a simple calculation with a potential deadly effect to a calculator, things are apt to go wrong.
It is a truth universally acknowledged that people who operate on hearts know which way the blood goes round; people who wish to inject dangerous drugs are expected to be able to find out how much to inject. They are not permitted to claim "I was never any good with figures"-if that's too tough they need to look for a job in Ethics or something.
You take a piece of paper, round the numbers to integers, get the powers of 10 correct, and get the rough answer. Then see if it's reasonable. Then use the calculator, spreadsheet or supercomputer, if you can't rid yourself of the delusion that the more decimal places the better. Surely the combination of A-levels, years at medical school and MMC can achieve this without pleading that we are helpless victims of those terrible computers.
Isn't the Public entitled to expect that a little thought has gone into 'fail-safing' these systems, in view of the inevitable failure of components? I suggest a little notebook with writing in it. “
For a major, refereed clinical journal to publish such an article just leaves me speechless and plays to the prejudice of the one or two Luddite practitioners who are still out there and seem to be found within the walls of the BMJ editorial offices.
The BMJ and its editors are guilty of the most amazing logical over-reach I have seen in years and are to be condemned for their stupidity.
This said, of course any computer program that is used in clinical care delivery needs to be robustly tested before deployment and the use of facilities such as range-checking and so on are vital – as is usability and safety testing to ensure safe program operation. The lesson here, if there is one, is that any programs used to support clinical care delivery need to be professionally and responsibly evaluated both for clinical and technical safety before deployment. Creation of such tools is not something to be done by enthusiastic but technically limited amateurs who do not appreciate the possible risks they run.
David.
2 comments:
The problem here is not the technology.
The problems that led to the death of the infant in this case are procedural. Anyone working in a safety-critical industry could point out the flaws:
1. The intern was working at reduced capacity due to a long shift (and probably a 90-hour week). No airline pilot is allowed to do this.
2. There was no second-person check of a safety-critical calculation, to independently verify that the doses were correct.
3. Software developed without rigorous, safety-critical system design processes was being used in a safety-critical application. No aircraft is flown using Excel. Even if it was, the spreadsheet would've been extensively tested, verified, and under strict version control.
4. There was no organisational policy to regulate the tools used for the drug calculation.
Calculating dosage by pen may help by providing a second, verifying calculation. But the reality is that the pen calculation is much more likely to be in error - particularly at the end of a long shift.
Let's stop making Luddite suggestions about getting rid of computers. They can make medicine much safer. Until we focus less on the technology and more on the the real, systemic safety problems, patients will continue to die.
It is technology that has drastically reduced the instances of death. Let me tell you of my own experience. When my son was diagnosed with a rare blood disorder called aplastic anemia, he had to have constant platelet transfusions. As he would be a potential candidate for a bone marrow transplant, it would be necessary to ensure he gets irridated platelets that would remove the danger of the markers from rejecting the transfusion. Yet, when the nurse handled the transfusion, he was providing normal non-irridated platelets which I objected vehemently. But to no avail because he was the nurse! Finally, when the charge nurse knew about it, she made a report on this lapse of procedural discipline. Now, this isn't a computer problem. It goes to show many times it is human error and procedural mistakes. In this case, even despite my objections, the nurse continued in his erroneous ways.
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