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VA staff flag dangerous errors in Oracle-built electronic health record

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Re: VA staff flag dangerous errors in Oracle-built electronic health record

#31

Post by nradov »

harvey9 wrote: post #24
Y-bar wrote: post #11

Meanwhile in Sweden: > Scrapping the millennium: introduction of a health record in Sweden fails > The introduction of a new, heavily criticized electronic journal system from Oracle in two Swedish health districts has failed spectacularly. https://www.heise.de/en/news/Scrapping-the-millennium-introd...

"An external audit by the auditing firm KPMG..." Piling one nonsense upon another. I worked with them on a different health project. After much song and dance we ended up with another bland slide deck.

The audit and consulting practices at KMPG and similar organizations are almost completely separate. And in fairness to KPMG, a bland slide deck is exactly what their customers want. If a hospital wanted groundbreaking disruptive innovation then they wouldn't hire a management consulting firm in the first place.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#32

Post by nathan_douglas »

nradov wrote: post #23
nathan_douglas wrote: post #20

Earlier quoted context omitted.

VistA is an old system, and it's definitely "aging." But the thing is that it actually works really, really well. For instance, it kills a remarkably low number of people, which is one of the benchmarks I personally value in an EHR. One of the interesting things about this is that, from my perspective, VistA's sort of a mesh of servers rather than the hierarchy we might expect from a federal system. Perhaps that's be…

VistA EHR works reasonably well for end users but the problem is that the underlying platform is kind of a dead end. There's no practical technical path to keep it moving forward with major new enhancements (some of which are legally mandated for compliance). Hardly any developers have the platform skills, no one wants to learn (career suicide in most cases), and modern tools don't support it. It's a shame but that's…

I don't disagree at all (disclaimer: I don't work on VistA, but systems that communicate with VistA... close enough that the "career suicide" phrase hits a little close to home).

I think the bigger problem is that we're not meaningfully grappling with the reality of what it takes to replace legacy government systems.

Another grain of sand on the beach of things that we're completely unequipped to deal with, I guess.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#33

Post by cratermoon »

skeptical_md wrote: post #6
jermaustin1 wrote: post #4

Earlier quoted context omitted.

I wouldn't trust that a nurse or doctor that is bedside to flag that either, though. Hospitals are woefully understaffed, and while they will do there best, we are all just humans. My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurs…

I am very sad to hear that your grandmother died as a result of a medical error, but the details of the story as you remember them aren’t quite plausible. 1) Metformin is not available in an IV formulation 2) Metformin itself is not nephrotoxic It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.

I don't see any mention of IV in the OP comment.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#34

Post by cratermoon »

epcoa wrote: post #15
cratermoon wrote: post #3

I once flagged a bug in Epic, the big EHR system. The system had somehow mixed up kilograms and pounds. For example, a normal adult male weight of 150lbs would be ~68kg, But accidentally save it without converting and get 150kg. Convert back and it becomes 330lbs. Suddenly our reasonably slim man becomes grossly obese. It's not just wrong, it's extremely dangerous. In an emergency situations, where morphine is common…

Opioids are not weight based dosed for adults. Typically pain protocols start at fixed doses based on prior opioid use and titrate up for effect. Also was this a bug in Epic proper or a site specific customization?

OK, so my example is flawed, but the scenario remains valid. I was going off charts like https://nursing.duke.edu/sites/default/files/documents/SCD-O...

I don't know anything about the bug other than my provider who I'd communicated and demonstrated the behavior to came back to me confirming that it was a real bug and was being fixed.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#35

Post by cratermoon »

harvey9 wrote: post #26
cratermoon wrote: post #3

I once flagged a bug in Epic, the big EHR system. The system had somehow mixed up kilograms and pounds. For example, a normal adult male weight of 150lbs would be ~68kg, But accidentally save it without converting and get 150kg. Convert back and it becomes 330lbs. Suddenly our reasonably slim man becomes grossly obese. It's not just wrong, it's extremely dangerous. In an emergency situations, where morphine is common…

In emergency situations (or even routine ones) where I'm administering morphine, I don't need a computer to help me figure out the dose. There are more complex dose calculations where good tech matters far more. Harold Thimbleby has some very accessible talks on safety in health tech: https://www.youtube.com/watch?v=AobMb3S5OtY&t=1034s

I suppose I'd better change my example to something that is more dependent on accurate weight. I do know that at one point there were weight/dose charts for morphine administration, e.g. https://nursing.duke.edu/sites/default/files/documents/SCD-O... but that could be an outdated practice.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#36

Post by sema4hacker »

sc68cal wrote: post #12
sema4hacker wrote: post #10

I'm amazed that city, county, state, and federal tech projects never want to clone best-of-show systems instead of starting from scratch. City needs a web site? Clone the best one you can find amongst the tens of thousands of cities already doing that. County jail needs tracking of inmate transports? Clone the best one you can find amongst the thousands of counties already doing that. State needs a sales tax system?…

That's what they did. If you read the article, it discussed the whole program as being a change from an in house developed system, to an off the shelf system. > The program launched in 2018 to replace the aging computer system used across VA’s health care network, which serves more than 9 million veterans, with an off-the-shelf product that could handle many of the same tasks: organizing important information includi…

Any time you hear a vendor is being selected "without competitive bidding", you're probably not getting the best solution.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#37

Post by moioci »

cratermoon wrote: post #33
skeptical_md wrote: post #6

Earlier quoted context omitted.

I am very sad to hear that your grandmother died as a result of a medical error, but the details of the story as you remember them aren’t quite plausible. 1) Metformin is not available in an IV formulation 2) Metformin itself is not nephrotoxic It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.

I don't see any mention of IV in the OP comment.

It says the second dose was "injected."

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#38

Post by amypetrik8 »

I'll tell you how "dangerous errors" work in practice in a hospital

Let's say we design a "dangerous errors" system. What it's going to consist of is some "are you sure you want to do that" style popups, and some sort of error reporting system.

The error reporting system (human entered) is where it gets interesting. The real nasty errors dutifilly get reported, no choice. The nasty and/or embarrassing errors are not reported. You get some of what they call "virtue signalling" errors where a person may report themself and pat themselves on the back for it - small errors. And than finally, about 1-5% of staff, the sorts that don't belong in medicine, will use it as their personal vendetta machine, ham up, falsify, fictionalize stories written against whoever it was that crossed them that day. Every day.

There CAN be on honest fair reporting system in the absolute healthiest of work cultures, with trust i.e. if I disclose I did something wrong I am confident that I won't be in trouble (that also means nobody can character assassinate someone else who crossed them - they won't be in trouble). But medicine, it's the opposite of such a culture, viciously political, unethical interpersonal practices, obsession with preserving ones career, license, and legal exposure over the common sense best interests of the patients.

Re: VA staff flag dangerous errors in Oracle-built electronic health record

#39

Post by mogwire »

cerneroracle wrote: post #22

I used to work at Cerner for a couple years. Honestly working at Cerner was a decent experience. Biggest private employer in Kansas City so everyone knew about the company. Huge campuses across Missouri and Kansas. Huge gym in HQ campus. I was aware of this VA project at the time, although I was no part of it. I knew it was going to take years and we basically had no competition. Shortly before I left the company we…

I supported Cerner RHEL servers for 6 years and Cerner is a joke.

Everything has to run as root.

All their scripts are Korn shell hacks from the 90s that have been carrier over.

Their god awful Kickstart scripts were written in stone even if you prove that there were better ways.

Cerner controlled the root password.

Cerner123!

They hard coded passwords with ROT13.

No wonder Oracle bought them.

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