A study published online in the Journal of the American Medical Informatics Association demonstrates how a simple software update can create unintended consequences that can have an adverse impact on patient care.
Doctors from Boston's Brigham and Women's Hospital in Boston, led by Adam Landman, M.D., were inspired to explore the problem when the hospital's information systems help desk was inundated with calls from physicians who could no longer access a web-based image viewer from the emergency department's tracking board.
The link from the ED tracking to the web-based image viewer was lost on workstations running Microsoft Explorer 6. It turned out the cause was a security update Microsoft had released days earlier.
According to the authors, it took 10 days to completely restore the link--the solution was to update all emergency department workstations to Internet Explorer 8.
In the 10 days after the link loss, 450 emergency department radiology studies were performed, compared to 52 during the previous 10 days. The web-based image viewer was used to review images just 1,281 times during this period, compared to 2,098 times in the 10 days before the link was lost.
"This case highlights the importance of hazard analysis and testing all software updates to clinical workstations," the authors wrote, "including applications on which HIT applications are built, such as operating system and web-browser updates."
This case also shows, the authors wrote, that hospitals must keep clinical workstation operating systems and web browsers up-to-date, but should do so by disabling auto-updates, while creating a formal process for updating clinical applications and operating systems software. This should help avoid the unintended consequences experienced in this case.
To learn more:
- see the study abstract