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

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

#61

Post by darpa_escapee »

zamadatix wrote: post #59
fucking_tragedy wrote: post #4

Earlier quoted context omitted.

> But more than anything already listed... the nurse didn't question giving someone 38 pills beyond "must be dilluted" yet the article pushes the focus to how technology led to the error? The nurse did question it further. I feel as though the articles addressed this and your subsequent point pretty adequately. > Since the Paleolithic Era, we humans have concocted explanations for stuff we don’t quite understand: tid…

I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted". Is any other line here actually relevant to technology or just how errors end up occurring even though you have resilient systems and checks built in? I.e. what about any of those has to do with technology itself?

> I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted".

From the above:

> The idea that the Septra might have been diluted was the first of many rationalizations that Levitt would formulate to explain the unusual dose and to justify her decision to administer it.

If you read the rest of the article, and not just what I've selected, there are multiple points in which the author quotes the nurse about her decision making process.

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

#62

Post by userbinator »

eesmith wrote: post #49
Aeolun wrote: post #40

Earlier quoted context omitted.

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 oth…

It's unfortunate (in the "safety rules are written in blood" manner), but now there's a datapoint that says a 38x overdose of Septra may be survivable, and what the effects can be.

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

#63

Post by thomasfedb »

leereeves wrote: post #56
thomasfedb wrote: post #54

Earlier quoted context omitted.

> Order of magnitude errors aren't that hard, it is improbable that a hospital will need to prescribe enough drugs for a small horse. Weight range in children's hospitals ranges from 100s of grams to 100s of kilos - that's three orders of magnitude right there. > Doctors seem to run too much on autopilot, they leave discretion to laboratories who give recommended ranges for various hormones/vitamins/chemicals in the…

Doesn't the system know the patient's weight?

Some systems do, but even then not in all situations. In my hospital we prescribe on paper anyway.

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

#64

Post by zamadatix »

darpa_escapee wrote: post #61
zamadatix wrote: post #59

Earlier quoted context omitted.

I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted". Is any other line here actually relevant to technology or just how errors end up occurring even though you have resilient systems and checks built in? I.e. what about any of those has to do with technology itself?

> I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted". From the above: > The idea that the Septra might have been diluted was the first of many rationalizations that Levitt would formulate to explain the unusual dose and to justify her decision to administer it. If you read the rest of the artic…

I read all of the parts before making my first comment in the thread. I think you and I must disagree on what I meant by questioning the large dosage. I don't mean it as a thought exercise involving just the nurse trying to figure out why the dosage is so irregular rather the physical questioning process of validating the odd dosage with the assigning doctor before prescribing.

I pointed it out not to say it's all the singular nurses fault but rather something glossed over in an article written against a technology system that had it's safeguards purposefully disabled. If anything the human error presented in the article is many times greater than technology error, reading the headline I expected the pill robot to have some error relating to batch size or some code error converting units wrong not a single confusing UI element as part of a string of overall hospital process and validation errors.

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

#65

Post by skwb »

zamadatix wrote: post #60
skwb wrote: post #50

Earlier quoted context omitted.

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 m…

"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." This isn't limited to us now using technological systems for steps. Unless you're arguing the portion of the article covering how the same errors used to happen more often before the system was put in place is incorrect. Fixing ALL false alerts is an…

I think the main points of the article is to introduce the potential complexities and pitfalls that come along with the digitization of clinical records and workflows. In my personal experience, engineers that haven't worked within a clinical setting always tend to struggle with how complex healthcare actually is, and that it requires a ton of nuance for understanding how to successfully develop digital clinical tools.

The other concern is that unlike Google, FB, or Uber, tech is not the funding priority of a healthcare system. They do spend money on large contracts for fully fledged EHR system (and a bunch of add ons), but because fundamentally it's an infrastructure problem and IT for healthcare systems are cost center, they're never going to be able to replicate the techno-centric workforce. I say this as someone who is intimately involved in developing technology for the healthcare system. But you do what you can; clinical informaticists (which is developing as it's own sub-specality) try to reduce the load, and do take on the continuous development of EHR systems. Asking for a level of polish that is unachievable isn't going to promote optimism.

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

#67

Post by mainAccount »

dang wrote: post #66
compelledToken wrote: post #12

[flagged]

We've banned this account for obvious reasons. Posting like this will eventually get your main account banned as well, so please don't do this. https://news.ycombinator.com/newsguidelines.html

  will eventually get your main account banned as well
Please do it now. The sooner the better.

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

#68

Post by fucking_tragedy »

zamadatix wrote: post #64
darpa_escapee wrote: post #61

Earlier quoted context omitted.

> I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted". From the above: > The idea that the Septra might have been diluted was the first of many rationalizations that Levitt would formulate to explain the unusual dose and to justify her decision to administer it. If you read the rest of the artic…

I read all of the parts before making my first comment in the thread. I think you and I must disagree on what I meant by questioning the large dosage. I don't mean it as a thought exercise involving just the nurse trying to figure out why the dosage is so irregular rather the physical questioning process of validating the odd dosage with the assigning doctor before prescribing. I pointed it out not to say it's all th…

The way I see it is even if the machinations of the process worked 100% in accordance to their specification or programming, in the end what matters is how people will respond to the system. If a system correctly shows a warning when a bad prescription is ordered, it is still faulty if the overall system encourages the user to ignore warnings.

In this case, the system must deal with human error. The system must factor in the fact that the people who interact with the system are UI/UX laymen, they're most likely overworked and sleep deprived. Perhaps it should not offer the option to override warnings. Perhaps warnings should be expressed in such a way that the user doesn't learn to ignore them in order to do their job

Perhaps fault falls on EPIC for allowing errors to be suppressed, or for having a UI that allows prescriptions to be written with ambiguous units, or the hospitals IT staff for suppressing the warnings. The argument can be made that the hospitals upper management can be blamed for hiring and scheduling practices that result in staff overworking or having to ignore software warnings.

All I know is that blaming human error has been tried for decades and results haven't changed. Maybe the overall system, top to bottom, needs to be reworked.

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