It Is A Pity That We Don’t See More Balanced Views On Clinical Software Errors.

This appeared las week:

Medical software blamed for fatal anticoagulant double-dosing error

Hospital doctors relying on the Cerner system accidentally prescribed an additional dose of apixaban

11th March 2021

By Antony Scholefield

A hospital software system has been blamed for a fatal anticoagulant double-dosing error after it displayed a prescribing icon so small that it could not be seen on a standard computer screen. 

In 2019, Ian Fraser was admitted to the Sunshine Hospital in Melbourne with an exacerbation of his congestive cardiac failure as well as community-acquired pneumonia.

He had a complex medical history ranging from rheumatoid arthritis and COPD to hypertension, AF and osteoporotic spinal crush fractures, with the result that he was on 14 different regular medications, including anticoagulants.

The 68-year-old eventually underwent a pleural tap. His condition improved slightly and he was restarted on enoxaparin.

During this time however, a respiratory registrar using the hospital’s Cerner electronic medical records system attempted to prescribe Mr Fraser apixaban as a discharge medicine.

He initially made a mistake, inadvertently writing the script as an inpatient order.

The registrar realised what had happened two minutes later and tried to correct it. Thinking that he had been successful, he remained unaware that the inpatient order was still active.

Soon after his pleural tap, Mr Fraser was transferred to the nearby Footscray Hospital for a pleurodesis and decortication.

Since the registrar’s script was in the Cerner system, just before Mr Fraser was due to undergo the procedure he was given an additional dose of apixaban on top of the enoxaparin. 

According to the Victorian coroners court, he subsequently developed a large retroperitoneal haematoma and died two weeks later.

Following the death, a hospital review concluded the incident was a result of the medical software, a system used in multiple public hospitals in Victoria.

The review said the electronic medical record had displayed both the inpatient and discharge medication on the same screen.

However, the icon used to differentiate inpatient from outpatient medications was "too small to be appreciated on a standard computer monitor".

This resulted in the doctor inadvertently suspending the discharge script rather than the inpatient script.

The review also discovered that the Cerner system had no alert to warn that a patient was being prescribed two medications of the same class

It also said the system's terminology was unnecessarily confusing.

"Medications are 'ordered' for inpatients and 'prescribed' for discharge. Medication orders/prescriptions can be either 'discontinued', 'suspended' or 'withheld'."

The Sunshine Hospital originally planned to prevent a repeat of the adverse event by updating its version of the Cerner software and giving more training to doctors on how to use it.

The hospital also said it would ask the Cerner Corporation, a $20 billion US-based company, to fix the problem globally.

But an expert report given to the coroners court said offering more training to doctors implied Mr Fraser’s death was the result of a “user error” when in reality it was a "user interface design induced error".

"Training without addressing the underlying usability issues is relatively ineffective, particularly considering the high staff turnover rate of the public hospital system," the expert report said.

…….

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More information: Coroner's findings

More here:

https://www.ausdoc.com.au/news/medical-software-blamed-fatal-anticoagulant-doubledosing-error

It really seems to me that coroners and others are all to quick to blame software for patient harms and deaths without considering that in pretty much every case the cause of a problem is multifactorial.

In this case we have all sorts of factors involved for example.

There are pretty much always user unfamiliarity or training issues found.

There are potentially local system configuration issues which my have affected the display of medication and possibly purchase of less than optimal monitors to display the screens ideally.

There are very often UI design issues which may or may not be important.

As the last line of defence against problems remember someone has to actually administer medications – are they not at least partially for giving two similar medications, without checking.

Any expert who says an issue is “user interface design induced error" as a sole cause of death is not worthy of being called an expert IMVHO.

All this said we need to remember 2 things:

1. Cerner is involved in supporting the delivery of care to 1000’s of patients each year and very few come to harm! Many more errors originate elsewhere in the system.

2. Analysis of each of these sorts of events should be a ‘teachable moment’ for all those involved in software systems so sensible overall incremental improvement can be fostered in a sensible and controlled fashion.

The essential truth to remember is that every software system assisting care has a human telling it what to do!

David.