Chicago Tribune reporters Judith Graham and Cynthia Dizikes explore the pitfalls of health information technology through the story of an infant boy who survived despite being born months early and weighing just 1.5 pounds, only to be killed by a sodium chloride overdose when a pharmacy tech entered information into the wrong field of his electronic medical record.
The tech’s fatal clerical error was compounded by disabled alarms on a compounding machine, incorrect labeling on an IV bag and an ignored lab test. The heart of the errors, the reporters write, seems to be that all the different systems involved don’t communicate.
Almost all medication requests at Advocate are transmitted by a doctor’s keystroke to the hospital pharmacy’s drug-dispensing system. But in this case, there was no electronic connection with the automated compounding system that prepared the IV bag for baby Burkett, a specialized device that handles low-volume, highly individualized orders.
So a technician transcribed the order by hand, and an error was introduced.
Electronic communication gaps are common at large hospitals, which typically use upward of 50 to 100 different information systems at their facilities, with different technologies used in emergency rooms, labs, pharmacies and other medical departments, said Ross Koppel, a sociologist at the University of Pennsylvania who studies health information technologies.
“To some degree these systems talk to each other, but mostly they don’t, so hospitals have to design custom-made software ‘bridges’ to make this happen,” Koppel said. With each jury-rigged software solution comes the potential for new software bugs, transcription errors and other problems.