Quite frankly, as a software engineer who works next to a couple medical companies, I won't let automation near me in medical contexts. I've had more than one coworker get hired by a medical device company and peace out a couple months in after seeing their codebase. Stuff like panics on any error that then set morphine pumps to full on. Not the worst way to die, but not the way I want to go...
Technology led a hospital to give a patient 38 times his dosage
21–30 of 68 posts
Re: Technology led a hospital to give a patient 38 times his dosage
#22The nurse is the the only "professional" human in the entire chain who actually handled the obviously anomalous dose of medicine, and she didn't raise a flag.
As more of the pipeline becomes automated and vulnerable to GIGO, the role of those physically administering the medication needs to adapt accordingly. The nurse should have been trained and encouraged to police such errors. If something looks abnormal, it probably is, push the button that summons the MD to verify the physical thing before administering it.
Re: Technology led a hospital to give a patient 38 times his dosage
#23Earlier quoted context omitted.
Wow the amount of "blind trust and no check" is staggering in the whole chain.
I wonder how common this is? And to think that many are led to believe that the medical system is filled with "professionals" who know what they're doing. I see enough people just blinding trusting the "experts", because they must be right, because they were trained by a university/college for many years. Maybe I'm ranting, but I'm sick of blind faith in a system demonstrated more often than not, to be broken in vari…
Have had docs prescribe med combos (same doc, same visit) that would have resulted in permanent damage or death if not caught. Luckily we have three people check all my other half’s meds before she takes them. She does an FDA search and checks drug/drug interactions. I do one independently and her father, idk what he does, but he’s actually an oncologist so presumably better than our checks. (Outpatient)
Too many close calls over the years. People make mistakes, it happens, ultimately the patient needs to be responsible for their care or have someone acting in their best interests.
Of course all of this gets into things like medically informed consent and patient goals.
Re: Technology led a hospital to give a patient 38 times his dosage
#24[flagged]
tl;dr you made the same mistake the hospital did with the units. kg * mg is g^2, which is most certainly not the correct unit for a dose.
If measured in mg/kg (actually a dimensionless ratio), multiply by weight in kg and the kg cancels out to give you the actual dose in mg.
Re: Technology led a hospital to give a patient 38 times his dosage
#25The nurse is the the only "professional" human in the entire chain who actually handled the obviously anomalous dose of medicine, and she didn't raise a flag. As more of the pipeline becomes automated and vulnerable to GIGO, the role of those physically administering the medication needs to adapt accordingly. The nurse should have been trained and encouraged to police such errors. If something looks abnormal, it prob…
I imagine it won't get any better when the physical administration of all medication also gets automated... like it already is for intravenous systems.
A hacker getting access to such systems would literally be able to control a patient's life --- or the end thereof.
Re: Technology led a hospital to give a patient 38 times his dosage
#26Earlier quoted context omitted.
I wonder how common this is? And to think that many are led to believe that the medical system is filled with "professionals" who know what they're doing. I see enough people just blinding trusting the "experts", because they must be right, because they were trained by a university/college for many years. Maybe I'm ranting, but I'm sick of blind faith in a system demonstrated more often than not, to be broken in vari…
I suspect it's pretty common. I recently corrected a prescription / dosing issue with my 89-year-old grandfather that was largely the result of the people involved not sanity-checking what was going on. I'm still of the opinion that most people are better off letting doctors and nurses do their job than trying to manage their own health based on stuff they've read on the internet. There's a lot of bad information out…
I’m sorry I usually try not to do this but this is some seriously dangerous advice.
It took me literally 30 seconds to find the interaction you’re talking about while tapping about on my phone. Being informed about side effects and interactions needs to be the patient’s (or their family) job.
The space may be alien but we have people who we are paying to help Sherpa us through it. Ask questions. Ask why. If you don’t understand don’t blindly trust - ask your doctor. Seek second opinions.
I’m just a dev, I have 0 medical training. But I know the FDA publishes side effects and interactions. I always understand these before taking anything. Yeah I don’t understand the gibberish in pharmacology sections of things but I can read a list of effects and ask a doctor about them.
TLDR - if you don’t understand your care ask. If the provider won’t explain find another provider who will.
Re: Technology led a hospital to give a patient 38 times his dosage
#27Quite frankly, as a software engineer who works next to a couple medical companies, I won't let automation near me in medical contexts. I've had more than one coworker get hired by a medical device company and peace out a couple months in after seeing their codebase. Stuff like panics on any error that then set morphine pumps to full on. Not the worst way to die, but not the way I want to go...
What's an error in this context?
Re: Technology led a hospital to give a patient 38 times his dosage
#28It's a poorly designed interface, but the real problem, IMO is that the nurse didn't double check with somebody before giving the kid 38 of the same pill. A dose like that just doesn't make sense, she should have known better.
That's quite a dismissive response for a complex issue.
Nurses deal with pills in all kinds of concentrations, particularly in pediatrics, and while I acknowledge that 38.5 pills doesn't pass the sniff test, it isn't absurd that in pediatric medicine you may wind up giving multiple lower dose pills relative to one full adult dosage (particularly if they're right below the adult dosage, and so a dosage was "created" using multiple lower dosage infant pills).
I think the article is terribly written (all five parts of it), but I cannot see how anyone could have read it and come away with the conclusion that "the nurse did it." There's like a million degrees of nuance here.
Re: Technology led a hospital to give a patient 38 times his dosage
#29Cliff notes-- New EMR/ordering system. New physician. New nurse. New pharmacy dispensing system. The physician couldn't order 160mg of Bactrim because per kg dosing was required. They mistakenly ordered 160 "mg/kg" (40x the intended dose of 4mg/kg) on the order screen. The UX on the screen was partly to blame-- dosing mg or mg/kg apparently came down to a just a dropbox. With EMR ordering systems I've used, this mist…
Wow the amount of "blind trust and no check" is staggering in the whole chain.
The problem is workload. All hospital staff is overworked. This is the number one reason problems happen.
Re: Technology led a hospital to give a patient 38 times his dosage
#30Quite frankly, as a software engineer who works next to a couple medical companies, I won't let automation near me in medical contexts. I've had more than one coworker get hired by a medical device company and peace out a couple months in after seeing their codebase. Stuff like panics on any error that then set morphine pumps to full on. Not the worst way to die, but not the way I want to go...
> I won't let automation near me in medical contexts
Is that even possible? Most of the machines are run by robots these days. Even simple devices (e.g. ECG monitor) has so much automation built into them.