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

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 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? I just can't see how this title was chosen beyond clickbait considering it has statistics included showing how this system has been more reliable than the classic solution.

> 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: tides, seasons, gravity, death. 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. At first glance it might seem crazy for her to have done so, but the decisions she made that night were entirely consistent with patterns of error seen in medicine and other complex industries.

> What is new for medicine is the degree to which very expensive, state-of-the-art technology designed to prevent human mistakes not only helped give rise to the Septra error, but also failed to stop it, despite functioning exactly as it was programmed.

> The human lapses that occurred after the computerized ordering system and pill-dispensing robots did their jobs perfectly well is a textbook case of English psychologist James Reason’s “Swiss cheese model” of error. Reason’s model holds that all complex organizations harbor many “latent errors,” unsafe conditions that are, in essence, mistakes waiting to happen. They’re like a forest carpeted with dry underbrush, just waiting for a match or a lightning strike.

> Still, there are legions of errors every day in complex organizations that don’t lead to major accidents. Why? Reason found that these organizations have built-in protections that block glitches from causing nuclear meltdowns, or plane crashes, or train derailments. Unfortunately, all these protective layers have holes, which he likened to the holes in slices of Swiss cheese.

> On most days, errors are caught in time, much as you remember to grab your house keys right before you lock yourself out. Those errors that evade the first layer of protection are caught by the second. Or the third. When a terrible “organizational accident” occurs — say, a space shuttle crash or a September 11–like intelligence breakdown — post hoc analysis virtually always reveals that the root cause was the failure of multiple layers, a grim yet perfect alignment of the holes in the metaphorical slices of Swiss cheese. Reason’s model reminds us that most errors are caused by good, competent people who are trying to do the right thing, and that bolstering the system — shrinking the holes in the Swiss cheese or adding overlapping layers — is generally far more productive than trying to purge the system of human error, an impossibility.

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 mistake is virtually impossible to make since weight-based dosing pops up a completely different window, calculates the dose and then goes back to the original dose screen showing the total dose.

That order went to a pharmacy robot which diligently counted out 40pills, put them in baggies and sent them to the nurse. The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct.

The medication error was noticed after the kiddo felt whole-body tingling. Poison control was called, but it didn't seem like they were able to give a clear treatment advice. A "rapid response" was called, they came and evaluated the patient. He was left in a non-ICU room. Several hours later he had a seizure. He recovered from the seizure and was then monitored in the ICU.

> 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?

Shit like this doesn't inspire confidence in me that the medical system is even functioning properly, half of the time.

Hmmmm. This assuages my annoyance, thankfully.