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.
In the heavily Puerto Rican Humboldt Park neighborhood, researchers worked with community leaders to write study questions, then relied on community members to conduct the actual survey. From these roots, the level of community participation snowballed, and locals demonstrated an interest and investment in public health that researchers hasn’t seen before. Today, initiatives born out of that study still provide residents with access to fresh produce, free diabetes screenings, fitness classes and more.
Now, researchers are further localizing and intensifying their effort with a block-by-block approach. The Humboldt Park model has become one that others are working to replicate across the country.
The specifics of the Sinai approach (In Humboldt Park) — change-oriented and invested in the fate of a neighborhood — are distinctive, but they also reflect a sea change in the overall strategy of public health professionals, said Janine Lewis, executive director of the Illinois Maternal and Child Health Coalition, a nonprofit advocacy organization in Chicago.
“I think the field is becoming more responsive to the idea of community-based participatory research,” Ms. Lewis said. “Those of us in the field realize that community members are experts on the needs and gifts in their communities, and should be consulted” at every phase of research.
This approach, she added, not only helps investigators devise more meaningful questions, but also means residents feel a part of the process and motivated by the results.
Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates AHCJ's social media efforts and edits and manages production of association guides, programs and newsletters.
A list of expected sessions for Health Journalism 2010 has been released and it includes panels and classes on the most timely health topics.
The conference, April 22-25 in Chicago, will feature sessions about finding and using health data, as well as how to map it, on Thursday. Field trips to see research and clinical work in the Chicago area are also planned for that day.
Panels on Friday, Saturday and Sunday will help reporters who are interested in tracking stimulus spending, understanding medical studies, comparative effectiveness research, conflicts of interest in medical research, vaccines, health reform, veterans’ issues, seniors and nursing homes and much more.
Conference registration for journalists is just $150 ($99 for students) and AHCJ negotiated a hotel rate of $139 at the Hyatt Regency McCormick Place, the conference hotel. A number of fellowships will be offered as well.
For those of you on Twitter, the hashtag #ahcj2010 has been designated for news about and from the conference. Follow AHCJ_Pia for all of the latest news from AHCJ.
The Chicago Tribune‘s Triage blog has closed its doors and Judy Graham – the face of the blog for the past year – has moved on to the paper’s investigative and watchdog team.
Graham will still find time twice a month to write the sort of stories Triage writers have come to know; fans will be able to find them in the pages of the Chicago Tribune‘s Sunday section and in other Tribune papers.