Of Scapegoating and Other Human Proclivities

Posted by: Peggy Salvatore, www.healthsystemed.com

The news could not be sadder. Premature baby boy Genesis Burkett was given an IV dose of sodium chloride 60 times greater than the physician ordered. The fatal infusion has professionals and loved ones all around the situation looking to place blame. It’s only natural. It is the worst of human tragedies and people need answers. Sometimes answers contain a kernel of peace – sometimes.

 For the details, the READ MORE.

In any case of error, medical or otherwise, there is usually some responsibility to go around, no matter how well intentioned or trained the people involved. I don’t know every detail and will try to refrain from passing any sort of judgment on a situation this sensitive to which I am not intimately privy. I do have, however, a few general thoughts on the issues as presented in the article. Those issues:

1. Some people are looking to blame the use of electronic patient records
2. An IV bag was allegedly mislabeled
3. A pharmacy tech input the dosage information into the pharmacy computer from a handwritten prescription
4. An automated alert system was not active when the information was entered

The initial interface with any electronic health record is the human who enters the data. Humans can only enter data they can accurately interpret or believe to be true. The hospital involved, Advocate Lutheran General Hospital in Park Ridge, Ill., apparently has reached the HIMSS Analytics Stage 6 of its health IT implementation, out of a possible 7, meaning it should have computerized physician order entry (CPOE) integrated into its system. In this particular case, it appears the relevant parts were not online and this prescription was outside that loop.

My gut reaction to this (and I’d like to hear yours, so please comment from your perspective) is that electronic health record systems are being asked to carry a lot of water when the bucket is still full of holes. A fully integrated and implemented health IT system, with well-trained staff and backup systems, may very well be positioned to avert tragedies such as these.

But we will never – and I use that term sparingly – be able to completely rely on any fully automated system in the care of human beings. The best health IT systems will accept, transfer, organize, analyze and process data that healthcare professionals enter. Electronic patient record systems will not have the capacity to look at the patient in front of them, determine that it is a frail infant that can fit in the palm of its father’s hand, and conclude that the dosage prescribed is far in excess of what is reasonable. Highly educated professionals, interacting with well integrated and fully implemented electronic health records, can deliver state-of-the-art care with the assistance of meticulously kept records and perfectly metered doses that match treatment protocols appropriate for the profile of the patient in front of them.

Medicine is yet an art as well as a science. And it is the most caring and skilled human beings, working in concert with finely tuned equipment, that will deliver quality care. In this imperfect world, under those conditions they will deliver it almost every time.

Comments

[Belstaff outlets]

I just sent this post to a bunch of my friends as I agree with most of what you’re saying here and the way you’ve presented it is awesome.