Baby's Death Spotlights Safety Risks Linked to Computerized Hospital Systems....

Chicago Tribune
July 01, 2011

CHICAGO _ The medical error that killed Genesis Burkett began with the kind of mistake people often make when filling out electronic forms: A pharmacy technician unwittingly typed the wrong information into a field on a screen.
Because of the mix-up, an automated machine at Advocate Lutheran General Hospital prepared an intravenous solution containing a massive overdose of sodium chloride _ more than 60 times the amount ordered by a physician.

When the nutritional fluids were administered to Genesis, a tiny baby born 16 weeks prematurely, the infant’s heart stopped and he died, leaving behind parents stunned by grief to this day.
Although a series of other errors contributed to the tragedy, its origin _ a piece of data entered inaccurately into a computer program _ throws a spotlight on safety risks associated with medicine’s advance into the information age, a trend being pushed aggressively under health reform.


The federal government is aiding the shift with $23 billion in incentives to medical providers who buy electronic medical records or computerized systems that automate drug orders and other medical processes. The hope is that these technologies will enhance access to vast amounts of information now tucked away in paper files and meaningfully improve medical care.
Doctors should be able to see test results quickly and communicate more easily with each other, for example. And electronic safeguards also can remind physicians about recommended medical practices or alert them to harmful interactions between medicines.


Yet with these sizable potential benefits also come potential problems. Hospital computers may crash or software bugs jumble data, deleting information from computerized records or depositing it in the wrong place. Sometimes, computers spew forth a slew of disorganized data, and physicians can’t find critical information about patients quickly.
Meanwhile, different electronic systems used in hospitals may not be able to communicate, and the alerts built into these systems are often ignored because they are so frequent and often are not especially useful, physicians and other experts report.


Technology vendors tend to dismiss incidents like the death that occurred at Advocate Lutheran General in Park Ridge as arising from human errors, not product deficiencies. But other experts say health information technologies can lead to mistakes when they aren’t in sync with the way medical providers work.
“We see problems much more often than we would like” because many health information systems are poorly designed and difficult for doctors and nurses to use, said Dr. Rainu Kaushal, chief of the division of quality and medical informatics at Weill Cornell Medical College in New York City.



Exactly how often safety concerns arise is not known. The U.S. Food and Drug Administration in December acknowledged getting 370 reports of problems involving health information technology since January 2008, including several dozen patient injuries and deaths, but those numbers are likely to be low because such reports are voluntary. Some examples:
_A patient died after a computer network problem caused delays in transmitting a critically important diagnostic image.
_Vital signs from patient monitors disappeared from electronic medical records after being viewed by hospital staff.

_A patient died after getting therapy meant for someone else after a wrong name was entered electronically on a scan performed by radiologists.
_Data about patients’ allergies were eliminated from medical records during an automatic computer update.
“(These) technologies can be enormously helpful, but what is emerging is that when implemented poorly, they can be harmful,” said Dr. Ashish Jha, associate professor of health policy at Harvard University’s School of Public Health and a member of an Institute of Medicine committee appointed late last year to study safety concerns associated with health information technology. That panel’s recommendations are expected to be issued in 2012.


Carla Smith, executive vice president of HIMSS, the industry’s largest trade group, based in Chicago, said that “safety concerns are on our radar screen” and “we want to make sure we have checks and balances in place (in vendor systems) to prevent unintended harm.”
The story of Genesis Burkett’s death at Advocate Lutheran General last October underscores the potentially devastating consequences of a single wrong piece of data put into a software system.
The infant’s parents, Fritzie and Cameron Burkett of Chicago, said they were overjoyed when their son, born four months early and weighing 1 pound 8 ounces, survived and began to improve under the hospital’s expert care. For about six weeks, the Burketts and other family members said, they were at the baby’s side, singing Christian music softly at his bassinet.


Having endured two previous miscarriages, the couple said they named the baby Genesis, signifying a new beginning.

For more Info on this story...

.http://nursinglink.monster.com/news/articles/22017-babys-death-spotlights-safety-risks-linked-to-computerized-hospital-systems?page=3