Infant death prompts calls for action on health IT errors

The tragic death of a baby in a Chicago hospital has again drawn attention to the potential of automated systems to generate the kinds of errors they're designed to prevent. These mistakes are serious and widespread enough that the Institute of Medicine last fall appointed a panel to investigate safety concerns associated with health information technology.

Some experts are calling for the mandatory reporting of adverse events related to HIT to a national database. They'd also like to see the creation of an independent panel that would work with providers to reduce the incidence of these events.

The incident's basics: Last October, Genesis Burkett, an infant born 16 weeks premature, died at Chicago's Advocate Lutheran General Hospital after he received a massive overdose of sodium chloride in an intravenous solution. A physician entered the order correctly in the hospital's computerized physician order entry (CPOE) system, but a pharmacy technician erred when re-entering the information into the IV compounding machine. Moreover, an alerting system that should have caught the mistake had been turned off.

These kinds of errors have been documented in a series of studies going back to at least 2005. A study published in the Journal of the American Medical Association that year found that a widely used CPOE system facilitated 22 types of error risks. Based on interviews with house staff at a major urban teaching hospitals, the researchers estimated that these CPOE-related errors occurred at least once a week. Still another paper found unintended consequences from CPOE the rule, rather than the exception.

On the other hand, CPOE is also seen as a key to improving patient safety. Studies have found that these systems offer numerous advantages over paper orders, mainly because they reduce ambiguity in orders and apply computerized decision support to prescribing decisions. Unfortunately, too many hospitals still require manual data entry into other systems that are not interfaced with CPOE, increasing the risk of human error.

To learn more:
- see the Chicago Tribune article
- read about the IOM panel on EHR-associated errors
- here's an abstract the JAMA study on errors associated with CPOE
- check out a Health Affairs paper on global use of CPOE


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