Need medicine at the hospital? Our study finds how often IT errors lead to the wrong drug or dose

Every time you are given medicine in the hospital the computer will prompt your doctor about the correctness of the medicine and its dosage.

Every time health professionals update patient records on the computer they need to fill in the correct information in the correct field, or select an option from a drop down menu.

But as more and more research shows, these electronic systems are not perfect.

Our new study shows how often these technology-related errors occur and what they mean for patient safety. They often occur as a result of programming errors or poor design and have little to do with the health workers using the system.

What did we look at? What did we find?

Our team analyzed more than 35,000 prescriptions at a major city hospital to understand how often technology-related errors occur.

We focus on errors made when medications are prescribed or computerized. In many hospitals, these systems have replaced the clipboard that hung at the end of the patient’s bed.

Our research has shown that one in three medication errors are related to technology. That is, the design or implementation of the electronic medicine system has facilitated error.

We also examined how technology-related errors have changed over time by examining error rates at three time points: during the first 12 weeks of using the system, and after 2 years. four and four after it is used.

We can expect technology-related errors to decrease over time as health professionals become more familiar with the systems. However, our research has shown that despite an initial “learning gap”, technology-related errors continued to be an issue for many years after electronic systems were introduced. implemented.

In our study, the rate of technology-related errors was the same four years after system implementation as it was in the first year of use.

How can mistakes happen?

Errors can occur for a number of reasons. For example, prescribers may be faced with a long list of possible dosages for a drug and accidentally choose the wrong one. This can lead to a lower than, or higher, target rate.

In our study, we found that dangerous drugs are often associated with technology-related errors. These included oxycodone, fentanyl and insulin, all of which can have serious side effects if prescribed incorrectly.

Technology-related errors can also occur any time a patient is monitored while a computer is being used.

Another case in the United States involved a nurse who obtained and administered the wrong medication. He found the medicine in a computer-controlled cabinet (known as an “automated dispensing cabinet”) that is used to store, dispense and retrieve medicines.

In an ingenious design, the cabinet allowed the nurse to search for the medicine by entering only two letters. A good design would not have presented drug options in only two letters.

A nurse chose and gave the wrong drug to a patient, which led to his cardiac arrest, and the nurse was charged with a crime.

Self-contained cabinets are being rolled out in Australian hospitals.

Earlier this year we heard about an error in South Australia’s medical record system. This mistimed the births of more than 1,700 pregnant women, possibly causing them to give birth prematurely.

We present a series of safety issues for the health system that describe and address specific examples of poor system design that we have identified during our investigations or others working in the system have brought to our attention. us.

These include a list of discounts that allow the administration of the drug by injection into the spine. This drug can be fatal if used in this way.

One features a built-in counter that rotates or drops medication dosages according to set rules. But this can lead to incorrect values ​​in very young or underweight children.

In each example, we include recommendations for improving the system. Organizations can then use these specific examples to evaluate their systems and take action.

What else can improve safety?

With the increasing digitization of our hospitals and health services, the risk of technology-related errors increases. And that’s before we talk about the potential for error in the artificial intelligence used in our health systems.

We do not request returns to paper-based records. But until we commit to the task of making computer-based systems safer, we will never fully benefit from the great digital systems that can provide health care.

Systems need to be constantly monitored and updated, ​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

Health IT managers and developers need to understand errors and recognize when system design is critical.

Since doctors are often the first to notice issues, there should also be methods to investigate and solve their problems immediately, supported by a systematic information of errors related to technology.