7 ms·

Cliff notes-- New EMR/ordering system. New physician. New nurse. New pharmacy dispensing system. The physician couldn't order 160mg of Bactrim because per kg do

by rcdmd 8y ago

Cliff notes-- New EMR/ordering system. New physician. New nurse. New pharmacy dispensing system. The physician couldn't order 160mg of Bactrim because per kg dosing was required. They mistakenly ordered 160 "mg/kg" (40x the intended dose of 4mg/kg) on the order screen. The UX on the screen was partly to blame-- dosing mg or mg/kg apparently came down to a just a dropbox. With EMR ordering systems I've used, this mistake is virtually impossible to make since weight-based dosing pops up a completely different window, calculates the dose and then goes back to the original dose screen showing the total dose. That order went to a pharmacy robot which diligently counted out 40pills, put them in baggies and sent them to the nurse. The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct. The medication error was noticed after the kiddo felt whole-body tingling. Poison control was called, but it didn't seem like they were able to give a clear treatment advice. A "rapid response" was called, they came and evaluated the patient. He was left in a non-ICU room. Several hours later he had a seizure. He recovered from the seizure and was then monitored in the ICU.

ekianjo 8y ago
Wow the amount of "blind trust and no check" is staggering in the whole chain.
- Valmar 8y ago
  I wonder how common this is? And to think that many are led to believe that the medical system is filled with "professionals" who know what they're doing. I see enough people just blinding trusting the "experts", because they must be right, because they were trained by a university/college for many years. Maybe I'm ranting, but I'm sick of blind faith in a system demonstrated more often than not, to be broken in various ways.
  - throwawayh09 8y ago
    It’s funny you belittle the medical profession considering any rando can make a Github account and apply for software jobs with zero training. No, the medical system isn’t perfect. It’s made up of humans, shocker. Ignoring the cost (in America), it does pretty well most of the time, and I’d rather blindly trust people who study medicine for 12+ years than someone who would otherwise try to drain my blood and balance my “humours”.
  - thomasfedb 8y ago
    Medication errors are common enough that they happen on a regular basis in any reasonably sized hospital. They happen both with or without electronic systems. The majority of errors are caught — by the prescriber, by the pharmacist, or by the nurse administering — but a few fall through the cracks. Order of magnitude errors, where the dose is x10^n the intended dose are some of the more common errors. We have a lot of safeguards — for example packaging medications in dosages that are likely to be safe for a single dose — but there are also some factors that make errors more likely, such as paediatrics (who need smaller does), geriatrics (who often have many different medications which can interact), and critical care (where things move fast, and big doses might be needed). I'm a student doctor, and hopefully you believe me that medicine is hard. Electronic systems might help with some of the hard bits, but they're often a hindrance, or pose their own hidden dangers. As a software engineer I know that a lot of medical software is far from fit for purpose.
    - ryacko 8y ago
      Order of magnitude errors aren't that hard, it is improbable that a hospital will need to prescribe enough drugs for a small horse. Doctors seem to run too much on autopilot, they leave discretion to laboratories who give recommended ranges for various hormones/vitamins/chemicals in the blood. I won't disagree that medicine is hard, but this looks like a UX design flaw, the UX should factor in drug company recommendations for dosage per patient weight and present a graph, there should be some method of compare and contrast to recognize an error happened.
      - skwb 8y ago
        Well university hospitals run lots of "experimental protocols" where physicians need the autonomy and flexibility for prescribe all sorts of medications. Just curation of drug-drug interactions tables is a huge butt-load of work, and we do have "hard stops" for all sorts of potentially dangerous interactions. Ultimately however, you need systems in place to control and regulate these systems (such as pharmacy, nurses, other physicians). Obviously this system had a major failure, but it's why this is the special exception rather than the rule. And for what it's worth, this article (by Bob Watcher, who basically invented hospital medicine) is part of any major graduate level healthcare education. One of the biggest problems I have seen with tech getting into healthcare is that they seem to forget the human interaction portion of healthcare that mostly happens offline. Yes, technology can have an enormous impact, but you can't just "technology" away all the problems in our current healthcare system.
  - thaumaturgy 8y ago
    I suspect it's pretty common. I recently corrected a prescription / dosing issue with my 89-year-old grandfather that was largely the result of the people involved not sanity-checking what was going on. I'm still of the opinion that most people are better off letting doctors and nurses do their job than trying to manage their own health based on stuff they've read on the internet. There's a lot of bad information out there and sorting through it takes practice. You have to enjoy reading medical literature more than blogs. The specifics: he's in a home hospice care situation as a result of severe aortic stenosis along with some complicating factors. Hospice is designed to provide "last two weeks" care for their patients, and they have a specific drug cocktail for that, but he's been on home hospice for over a year now because his body just isn't done yet, and there is no death-with-dignity law in his state (nor available providers in the neighboring state). The drug cocktail is an opioid, usually morphine, along with a benzodiazepine, usually Lorazepam (generic Ativan). Taken together, they help relieve anxiety, reduce respiratory distress, and lower blood pressure. That last is important, because the morphine/benzo cocktail is specifically cautioned against in medical literature for elderly patients who are still ambulatory, because it creates a fall risk. They go to stand up to use the bathroom, and there isn't sufficient blood pressure to stay conscious, and they pass out and hit the floor, hard. And that's exactly what happened to him. The third time, it hospitalized him and, because his speech had been slurred and his consciousness had been altered before the fall, I suspected his medication wasn't right. I went out there and carefully went through everything, and sure 'nuff, that's what it was. The doctors just prescribed whatever hospice asked for, and hospice just asked for their usual recipe. It took an annoying number of meetings with staff before a younger visiting physician dropped in to one of the meetings and followed up with the literature I was citing. The next morning they started reducing his dosages and he began recovering, including getting his mental faculties back. He's been back home for a couple of months now, doing well. Physicians aren't magic. But, they work in a field that's totally alien to most of us here on HN, and trying to navigate the field as a layman can easily lead you into some pretty woo-woo nonsense. Trust, but verify.
    - schreiaj 8y ago
      I’m sorry I usually try not to do this but this is some seriously dangerous advice. It took me literally 30 seconds to find the interaction you’re talking about while tapping about on my phone. Being informed about side effects and interactions needs to be the patient’s (or their family) job. The space may be alien but we have people who we are paying to help Sherpa us through it. Ask questions. Ask why. If you don’t understand don’t blindly trust - ask your doctor. Seek second opinions. I’m just a dev, I have 0 medical training. But I know the FDA publishes side effects and interactions. I always understand these before taking anything. Yeah I don’t understand the gibberish in pharmacology sections of things but I can read a list of effects and ask a doctor about them. TLDR - if you don’t understand your care ask. If the provider won’t explain find another provider who will.
  - schreiaj 8y ago
    Have had docs prescribe med combos (same doc, same visit) that would have resulted in permanent damage or death if not caught. Luckily we have three people check all my other half’s meds before she takes them. She does an FDA search and checks drug/drug interactions. I do one independently and her father, idk what he does, but he’s actually an oncologist so presumably better than our checks. (Outpatient) Too many close calls over the years. People make mistakes, it happens, ultimately the patient needs to be responsible for their care or have someone acting in their best interests. Of course all of this gets into things like medically informed consent and patient goals.
    - skwb 8y ago
      Well on the outpatient side, the volume of drugs a doctor is prescribing is horrendously outpaced by the number of order you're getting as a hospitalist. When you are responsible for about a dozen patients and some need your attention NOW, it's not feasible to do a complete drug-drug interaction check. But that's where A) the modern EHR that has been invested into it by the healthcare system to build drug-drug interaction tables, and B) relying on the hospital pharmacists to modify orders when necessary. It's about building a robust system that integrates human systems and enhancing them with technology.
      - schreiaj 8y ago
        Yup. I’m mostly advocating for patients to be active in their care. Stop blind trust.
- Justsignedup 8y ago
  The problem is workload. All hospital staff is overworked. This is the number one reason problems happen.
  - deleted 8y ago
    [deleted]
  - deleted 8y ago
    [deleted]
- Aeolun 8y ago
  If you read the article you will find that the amount of blind trust, as you call it, was created by the system saving the nurses ass a fuckton of times. Makes perfect sense to trust it at that point. I am more concerned that any medical system allows such a shitty UI, or allows giving something that could be a fatal dose through the system.
- wux 8y ago
  The problem, of course, is that elsewhere in the chain there was in fact too much checking and too little trust. In this case, it started with not trusting the physician to enter a known dose and requiring an unnecessary conversion, which kicked off the chain of events. This was immediately followed by the problem of alarm fatigue, where practically no set of medication orders can be entered without triggering a slew of useless automated warnings. The problem of having to deal with too many alarms is not unique to the hospital system mentioned in this article. I discovered the other day that at least one model of ventilator has an alarm that sounds when any object sits in front of the display screen. There was a stethoscope dangling in front of a corner of that screen where nothing was displayed, and an alarm went off of approximately the same urgency as one that would sound if the ventilator were about to blow a patient's lungs out. The same alarm that goes off when a patient's heart rate goes from 60 to 250 bpm sounds when the patient's heart rate goes from 99 to 101 bpm. The pharmacist who was supposed to be checking my orders for sanity once paged me out of a patient room because he couldn't find the URL for the hospital's policy on titrating a particular medication, a document issued by the pharmacy. Most people would agree that it's insane to text and drive on the highway, and yet this is essentially what's being expected of every physician in every hospital while they're making major medical decisions.
Valmar 8y ago
> The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct. How sad. This does lead me to wonder if said nurse, and other nurses, are properly trained to think for themselves. > Poison control was called, but it didn't seem like they were able to give a clear treatment advice. It gets worse... how come they weren't able to? Poor training? By-the-book training? Shit like this doesn't inspire confidence in me that the medical system is even functioning properly, half of the time.
- deleted 8y ago
  [deleted]
- Aeolun 8y ago
  Poison control never deals with someone that has taken 38 pills of antibiotics... I wouldn’t be surprised if that was the first time in their history.
  - eesmith 8y ago
    From the actual text, rather than the summary: > The doctor picked up the phone and called San Francisco’s poison control center. No one at the center had ever heard of an accidental overdose this large—for Septra or any other antibiotic, for that matter—and nothing close had ever been reported in the medical literature. The toxicology expert there told the panicked clinicians that there wasn’t much they could do other than monitor the patient closely.
    - userbinator 8y ago
      It's unfortunate (in the "safety rules are written in blood" manner), but now there's a datapoint that says a 38x overdose of Septra may be survivable, and what the effects can be.
onetimemanytime 8y ago
>>Several hours later he had a seizure. He recovered from the seizure and was then monitored in the ICU. A week later he was mailed the $421,455 bill for the services rendered due to overdosing /joking...unless they really do. In real life scenarios there must be more than just one robot deciding.
Pfhreak 8y ago
> The physician couldn't order 160mg of Bactrim because per kg dosing was required. Not quite. The article suggested that, yes, they could have ordered it in just mg. But they needed to change a dropdown from "mg/kg" to "mg", which is easily overlooked.
- rcdmd 8y ago
  No-- the patient's weight was just under 40kg-- the system logic completely disabled dosing by total dose.

by rcdmd 8y ago

ekianjo 8y ago

Wow the amount of "blind trust and no check" is staggering in the whole chain.

Valmar 8y ago
I wonder how common this is? And to think that many are led to believe that the medical system is filled with "professionals" who know what they're doing. I see enough people just blinding trusting the "experts", because they must be right, because they were trained by a university/college for many years. Maybe I'm ranting, but I'm sick of blind faith in a system demonstrated more often than not, to be broken in various ways.
- throwawayh09 8y ago
  It’s funny you belittle the medical profession considering any rando can make a Github account and apply for software jobs with zero training. No, the medical system isn’t perfect. It’s made up of humans, shocker. Ignoring the cost (in America), it does pretty well most of the time, and I’d rather blindly trust people who study medicine for 12+ years than someone who would otherwise try to drain my blood and balance my “humours”.
- thomasfedb 8y ago
  Medication errors are common enough that they happen on a regular basis in any reasonably sized hospital. They happen both with or without electronic systems. The majority of errors are caught — by the prescriber, by the pharmacist, or by the nurse administering — but a few fall through the cracks. Order of magnitude errors, where the dose is x10^n the intended dose are some of the more common errors. We have a lot of safeguards — for example packaging medications in dosages that are likely to be safe for a single dose — but there are also some factors that make errors more likely, such as paediatrics (who need smaller does), geriatrics (who often have many different medications which can interact), and critical care (where things move fast, and big doses might be needed). I'm a student doctor, and hopefully you believe me that medicine is hard. Electronic systems might help with some of the hard bits, but they're often a hindrance, or pose their own hidden dangers. As a software engineer I know that a lot of medical software is far from fit for purpose.
  - ryacko 8y ago
    Order of magnitude errors aren't that hard, it is improbable that a hospital will need to prescribe enough drugs for a small horse. Doctors seem to run too much on autopilot, they leave discretion to laboratories who give recommended ranges for various hormones/vitamins/chemicals in the blood. I won't disagree that medicine is hard, but this looks like a UX design flaw, the UX should factor in drug company recommendations for dosage per patient weight and present a graph, there should be some method of compare and contrast to recognize an error happened.
    - skwb 8y ago
      Well university hospitals run lots of "experimental protocols" where physicians need the autonomy and flexibility for prescribe all sorts of medications. Just curation of drug-drug interactions tables is a huge butt-load of work, and we do have "hard stops" for all sorts of potentially dangerous interactions. Ultimately however, you need systems in place to control and regulate these systems (such as pharmacy, nurses, other physicians). Obviously this system had a major failure, but it's why this is the special exception rather than the rule. And for what it's worth, this article (by Bob Watcher, who basically invented hospital medicine) is part of any major graduate level healthcare education. One of the biggest problems I have seen with tech getting into healthcare is that they seem to forget the human interaction portion of healthcare that mostly happens offline. Yes, technology can have an enormous impact, but you can't just "technology" away all the problems in our current healthcare system.
- thaumaturgy 8y ago
  I suspect it's pretty common. I recently corrected a prescription / dosing issue with my 89-year-old grandfather that was largely the result of the people involved not sanity-checking what was going on. I'm still of the opinion that most people are better off letting doctors and nurses do their job than trying to manage their own health based on stuff they've read on the internet. There's a lot of bad information out there and sorting through it takes practice. You have to enjoy reading medical literature more than blogs. The specifics: he's in a home hospice care situation as a result of severe aortic stenosis along with some complicating factors. Hospice is designed to provide "last two weeks" care for their patients, and they have a specific drug cocktail for that, but he's been on home hospice for over a year now because his body just isn't done yet, and there is no death-with-dignity law in his state (nor available providers in the neighboring state). The drug cocktail is an opioid, usually morphine, along with a benzodiazepine, usually Lorazepam (generic Ativan). Taken together, they help relieve anxiety, reduce respiratory distress, and lower blood pressure. That last is important, because the morphine/benzo cocktail is specifically cautioned against in medical literature for elderly patients who are still ambulatory, because it creates a fall risk. They go to stand up to use the bathroom, and there isn't sufficient blood pressure to stay conscious, and they pass out and hit the floor, hard. And that's exactly what happened to him. The third time, it hospitalized him and, because his speech had been slurred and his consciousness had been altered before the fall, I suspected his medication wasn't right. I went out there and carefully went through everything, and sure 'nuff, that's what it was. The doctors just prescribed whatever hospice asked for, and hospice just asked for their usual recipe. It took an annoying number of meetings with staff before a younger visiting physician dropped in to one of the meetings and followed up with the literature I was citing. The next morning they started reducing his dosages and he began recovering, including getting his mental faculties back. He's been back home for a couple of months now, doing well. Physicians aren't magic. But, they work in a field that's totally alien to most of us here on HN, and trying to navigate the field as a layman can easily lead you into some pretty woo-woo nonsense. Trust, but verify.
  - schreiaj 8y ago
    I’m sorry I usually try not to do this but this is some seriously dangerous advice. It took me literally 30 seconds to find the interaction you’re talking about while tapping about on my phone. Being informed about side effects and interactions needs to be the patient’s (or their family) job. The space may be alien but we have people who we are paying to help Sherpa us through it. Ask questions. Ask why. If you don’t understand don’t blindly trust - ask your doctor. Seek second opinions. I’m just a dev, I have 0 medical training. But I know the FDA publishes side effects and interactions. I always understand these before taking anything. Yeah I don’t understand the gibberish in pharmacology sections of things but I can read a list of effects and ask a doctor about them. TLDR - if you don’t understand your care ask. If the provider won’t explain find another provider who will.
- schreiaj 8y ago
  Have had docs prescribe med combos (same doc, same visit) that would have resulted in permanent damage or death if not caught. Luckily we have three people check all my other half’s meds before she takes them. She does an FDA search and checks drug/drug interactions. I do one independently and her father, idk what he does, but he’s actually an oncologist so presumably better than our checks. (Outpatient) Too many close calls over the years. People make mistakes, it happens, ultimately the patient needs to be responsible for their care or have someone acting in their best interests. Of course all of this gets into things like medically informed consent and patient goals.
  - skwb 8y ago
    Well on the outpatient side, the volume of drugs a doctor is prescribing is horrendously outpaced by the number of order you're getting as a hospitalist. When you are responsible for about a dozen patients and some need your attention NOW, it's not feasible to do a complete drug-drug interaction check. But that's where A) the modern EHR that has been invested into it by the healthcare system to build drug-drug interaction tables, and B) relying on the hospital pharmacists to modify orders when necessary. It's about building a robust system that integrates human systems and enhancing them with technology.
    - schreiaj 8y ago
      Yup. I’m mostly advocating for patients to be active in their care. Stop blind trust.
Justsignedup 8y ago
The problem is workload. All hospital staff is overworked. This is the number one reason problems happen.
- deleted 8y ago
  [deleted]
- deleted 8y ago
  [deleted]
Aeolun 8y ago
If you read the article you will find that the amount of blind trust, as you call it, was created by the system saving the nurses ass a fuckton of times. Makes perfect sense to trust it at that point. I am more concerned that any medical system allows such a shitty UI, or allows giving something that could be a fatal dose through the system.
wux 8y ago
The problem, of course, is that elsewhere in the chain there was in fact too much checking and too little trust. In this case, it started with not trusting the physician to enter a known dose and requiring an unnecessary conversion, which kicked off the chain of events. This was immediately followed by the problem of alarm fatigue, where practically no set of medication orders can be entered without triggering a slew of useless automated warnings. The problem of having to deal with too many alarms is not unique to the hospital system mentioned in this article. I discovered the other day that at least one model of ventilator has an alarm that sounds when any object sits in front of the display screen. There was a stethoscope dangling in front of a corner of that screen where nothing was displayed, and an alarm went off of approximately the same urgency as one that would sound if the ventilator were about to blow a patient's lungs out. The same alarm that goes off when a patient's heart rate goes from 60 to 250 bpm sounds when the patient's heart rate goes from 99 to 101 bpm. The pharmacist who was supposed to be checking my orders for sanity once paged me out of a patient room because he couldn't find the URL for the hospital's policy on titrating a particular medication, a document issued by the pharmacy. Most people would agree that it's insane to text and drive on the highway, and yet this is essentially what's being expected of every physician in every hospital while they're making major medical decisions.

Valmar 8y ago

> The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct. How sad. This does lead me to wonder if said nurse, and other nurses, are properly trained to think for themselves. > Poison control was called, but it didn't seem like they were able to give a clear treatment advice. It gets worse... how come they weren't able to? Poor training? By-the-book training? Shit like this doesn't inspire confidence in me that the medical system is even functioning properly, half of the time.

deleted 8y ago
[deleted]
Aeolun 8y ago
Poison control never deals with someone that has taken 38 pills of antibiotics... I wouldn’t be surprised if that was the first time in their history.
- eesmith 8y ago
  From the actual text, rather than the summary: > The doctor picked up the phone and called San Francisco’s poison control center. No one at the center had ever heard of an accidental overdose this large—for Septra or any other antibiotic, for that matter—and nothing close had ever been reported in the medical literature. The toxicology expert there told the panicked clinicians that there wasn’t much they could do other than monitor the patient closely.
  - userbinator 8y ago
    It's unfortunate (in the "safety rules are written in blood" manner), but now there's a datapoint that says a 38x overdose of Septra may be survivable, and what the effects can be.

onetimemanytime 8y ago

>>Several hours later he had a seizure. He recovered from the seizure and was then monitored in the ICU. A week later he was mailed the $421,455 bill for the services rendered due to overdosing /joking...unless they really do. In real life scenarios there must be more than just one robot deciding.

Pfhreak 8y ago

> The physician couldn't order 160mg of Bactrim because per kg dosing was required. Not quite. The article suggested that, yes, they could have ordered it in just mg. But they needed to change a dropdown from "mg/kg" to "mg", which is easily overlooked.

rcdmd 8y ago
No-- the patient's weight was just under 40kg-- the system logic completely disabled dosing by total dose.