Technology led a hospital to give a patient 38 times his dosage • Hacker News Board

Re: Technology led a hospital to give a patient 38 times his dosage

#41

Post by wux » Sat, Oct 06, 2018, 5:13 AM UTC

ekianjo wrote: post #7

rcdmd wrote: post #6

Cliff 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, of course, is that elsewhere in the chain there was in fact too much checking and too little trust. In this case, it started with not trusting the physician to enter a known dose and requiring an unnecessary conversion, which kicked off the chain of events. This was immediately followed by the problem of alarm fatigue, where practically no set of medication orders can be entered without triggering a slew of useless automated warnings.

The problem of having to deal with too many alarms is not unique to the hospital system mentioned in this article. I discovered the other day that at least one model of ventilator has an alarm that sounds when any object sits in front of the display screen. There was a stethoscope dangling in front of a corner of that screen where nothing was displayed, and an alarm went off of approximately the same urgency as one that would sound if the ventilator were about to blow a patient's lungs out. The same alarm that goes off when a patient's heart rate goes from 60 to 250 bpm sounds when the patient's heart rate goes from 99 to 101 bpm. The pharmacist who was supposed to be checking my orders for sanity once paged me out of a patient room because he couldn't find the URL for the hospital's policy on titrating a particular medication, a document issued by the pharmacy. Most people would agree that it's insane to text and drive on the highway, and yet this is essentially what's being expected of every physician in every hospital while they're making major medical decisions.

Re: Technology led a hospital to give a patient 38 times his dosage

#42

Post by exikyut » Sat, Oct 06, 2018, 5:14 AM UTC

userbinator wrote: post #11

Do you spot the problem? I saw it right away. That said, I agree with the article that the UI is horrible. It (and many other elements of this story) remind me of interacting with Enterprise software, although in that case people usually aren't in mortal danger because of it. I probably noticed it more because I saw the first screenshot with a "5" in the same box and thus "160" looks surprising, but even without that…

I also immediately saw everything in the screenshot, but I would have to join the ranks of the people mentioned who didn't raise their hands.

I'm relaxed right now and it's the weekend, I'm reading an article in downtime, I have precisely 0 other things going on... and I've been reading for the past 20 minutes about a broken system. Of course I'm going to be primed to take the screenshots to bits, and have sufficient mental bandwidth to do so very effectively on the first try.

>> Had Lucca noticed it, she could have changed it to “mg” with two clicks

> Two clicks? Just looking at it, this UI is not obvious at all to me how to even change the units.

Me neither. Perhaps clicking in the search box also opens a dropdown with default values in it? That would satisfy one click, two click.

Re: Technology led a hospital to give a patient 38 times his dosage

#43

Post by okayBro » Sat, Oct 06, 2018, 5:19 AM UTC

userbinator wrote: post #24

compelledToken wrote: post #12

[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.

Uh, go back and look at the screenshot.

The article explains that the system multiplied the number of pills by kilograms of body weight.

It's right in the title of the article, right at the top of this very thread.

38 times.

38 kilograms.

The let the computer system multiply the dose by body weight in kgs.

Re: Technology led a hospital to give a patient 38 times his dosage

#44

Post by Pfhreak » Sat, Oct 06, 2018, 5:21 AM UTC

rcdmd wrote: post #6

Cliff 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…

> The physician couldn't order 160mg of Bactrim because per kg dosing was required.

Not quite. The article suggested that, yes, they could have ordered it in just mg. But they needed to change a dropdown from "mg/kg" to "mg", which is easily overlooked.

Re: Technology led a hospital to give a patient 38 times his dosage

#45

Post by ryacko » Sat, Oct 06, 2018, 5:32 AM UTC

thomasfedb wrote: post #17

Valmar wrote: post #9

Earlier 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…

Medication errors are common enough that they happen on a regular basis in any reasonably sized hospital. They happen both with or without electronic systems. The majority of errors are caught — by the prescriber, by the pharmacist, or by the nurse administering — but a few fall through the cracks. Order of magnitude errors, where the dose is x10^n the intended dose are some of the more common errors. We have a lot o…

Order of magnitude errors aren't that hard, it is improbable that a hospital will need to prescribe enough drugs for a small horse.

Doctors seem to run too much on autopilot, they leave discretion to laboratories who give recommended ranges for various hormones/vitamins/chemicals in the blood.

I won't disagree that medicine is hard, but this looks like a UX design flaw, the UX should factor in drug company recommendations for dosage per patient weight and present a graph, there should be some method of compare and contrast to recognize an error happened.

Re: Technology led a hospital to give a patient 38 times his dosage

#46

Post by ummonk » Sat, Oct 06, 2018, 5:36 AM UTC

Even before I got to part 2, my immediate reaction was that having two types of inputs, dosage/weight and absolute dosage, would easily lead to confusion and seemed like a really bad idea.

It would seem to me much better to require the person to put in just the absolute dosage and have the computer show the actual nearest pill rounded dosage as well as the effective per weight dosage of that.

Additionally, instead of a routine alert, why not have a reactive red highlight/warning while the person is filling out the form? The person would actually see the issue while entering it, instead of just seeing an alert that they reflexively close out.

Re: Technology led a hospital to give a patient 38 times his dosage

#47

Post by skwb » Sat, Oct 06, 2018, 5:47 AM UTC

ryacko wrote: post #45

thomasfedb wrote: post #17

Earlier quoted context omitted.

Medication errors are common enough that they happen on a regular basis in any reasonably sized hospital. They happen both with or without electronic systems. The majority of errors are caught — by the prescriber, by the pharmacist, or by the nurse administering — but a few fall through the cracks. Order of magnitude errors, where the dose is x10^n the intended dose are some of the more common errors. We have a lot o…

Order of magnitude errors aren't that hard, it is improbable that a hospital will need to prescribe enough drugs for a small horse. Doctors seem to run too much on autopilot, they leave discretion to laboratories who give recommended ranges for various hormones/vitamins/chemicals in the blood. I won't disagree that medicine is hard, but this looks like a UX design flaw, the UX should factor in drug company recommenda…

Well university hospitals run lots of "experimental protocols" where physicians need the autonomy and flexibility for prescribe all sorts of medications. Just curation of drug-drug interactions tables is a huge butt-load of work, and we do have "hard stops" for all sorts of potentially dangerous interactions.

Ultimately however, you need systems in place to control and regulate these systems (such as pharmacy, nurses, other physicians). Obviously this system had a major failure, but it's why this is the special exception rather than the rule. And for what it's worth, this article (by Bob Watcher, who basically invented hospital medicine) is part of any major graduate level healthcare education.

One of the biggest problems I have seen with tech getting into healthcare is that they seem to forget the human interaction portion of healthcare that mostly happens offline. Yes, technology can have an enormous impact, but you can't just "technology" away all the problems in our current healthcare system.

Re: Technology led a hospital to give a patient 38 times his dosage

#48

Post by skwb » Sat, Oct 06, 2018, 5:52 AM UTC

schreiaj wrote: post #23

Valmar wrote: post #9

Earlier 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…

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 clo…

Well on the outpatient side, the volume of drugs a doctor is prescribing is horrendously outpaced by the number of order you're getting as a hospitalist. When you are responsible for about a dozen patients and some need your attention NOW, it's not feasible to do a complete drug-drug interaction check. But that's where A) the modern EHR that has been invested into it by the healthcare system to build drug-drug interaction tables, and B) relying on the hospital pharmacists to modify orders when necessary. It's about building a robust system that integrates human systems and enhancing them with technology.

Re: Technology led a hospital to give a patient 38 times his dosage

#49

Post by eesmith » Sat, Oct 06, 2018, 6:03 AM UTC

Aeolun wrote: post #40

Valmar wrote: post #8

Earlier quoted context omitted.

> The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct. How sad. This does lead me to wonder if said nurse, and other nurses, are properly trained to think for themselves. > Poison control was called, but it didn't seem like they were able to give a clear treatment advice. It gets worse... how come they weren't able to? Poor training? By-the-book training? Sh…

Poison control never deals with someone that has taken 38 pills of antibiotics... I wouldn’t be surprised if that was the first time in their history.

From the actual text, rather than the summary:

> The doctor picked up the phone and called San Francisco’s poison control center. No one at the center had ever heard of an accidental overdose this large—for Septra or any other antibiotic, for that matter—and nothing close had ever been reported in the medical literature. The toxicology expert there told the panicked clinicians that there wasn’t much they could do other than monitor the patient closely.

Re: Technology led a hospital to give a patient 38 times his dosage

#50

Post by skwb » Sat, Oct 06, 2018, 6:04 AM UTC

zamadatix wrote: post #2

This horribly written series of articles should be titled "How technology could not prevent a hospital from giving a patient 38 times his dosage". - The system's dosage caps were disabled - The dosage was never double checked since "technology is so accurate", ignoring people still make mistakes when using it - Vast swaths of alerts are regularly ignored rather than fixed resulting in them being ignored But more than…

The point you may have failed to get is that hospitals rely on systems for catching errors (which is hard because medicine is super hard). The point Wachler attempts to raise is how when we blindly substitute technological systems with human based processes we can miss the mark if we're not extra careful. Very important as we think about replacing human effort with that of robots (think Tesla vs. Toyota in how they make cars...).

I would also like to point out that simply fixing alerts isn't necessarily practical. When you're reliant on outside vendors for a highly regulated industry (requiring FDA approval of any and all changes), you can't exactly change on a dime. So while maybe we all in healthcare sneer at device manufactures, there's not a ton on the user side we can do.