VA staff flag dangerous errors in Oracle-built electronic health record
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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
#2Re: VA staff flag dangerous errors in Oracle-built electronic health record
#3I 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 commonly administered for extreme pain, the dosage needed to relieve the pain of a 330lb man would kill a 150lb man. Granted the responder at the patient's side would probably realize something is amiss, but a pharmacist in another room filling an order wouldn't have the context, and could make the error.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#4I 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…
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 nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it.
There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested.
Too many patients, too few doctors, and with Epic, too many button clicks.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#5Every user I’ve heard coming from a Cerner facility has said that Cerner is an unmitigated disaster.
It almost makes sense that the only way to get a customer was to essentially lobby and force your way into a government contract for it, and it’s still an unmitigated disaster.
My heart goes out to those that are going to get fucked over by this piss-poor deployment and be actually, physically harmed by bad EMR decisions and implementation choices.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#6I 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…
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.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#7I 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…
Wired covered the story twelve years ago of an Epic implementation failure that led to a child’s overdose (and recovery), of note:
https://www.wired.com/2015/03/how-technology-led-a-hospital-... https://archive.is/1QPmK
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#8Earlier 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 expect GP mistook metformin-associated lactic acidosis in a patient with kidney disease as something metformin-caused. A separate but coincident IV misadministration could be an exacerbating factor. It would have been a rare case, but a plausible explanation for the misunderstanding.
Metformin is relatively kidney safe and not administered by IV. Thank you for clarifying that for anyone that may currently on or considering Metformin. It would be great if medical professionals were infallible communicators and had time to verify understanding, but they are human and we need more doctors and less time-pressure by profit extracting private equity.
Disclaimer: I am not a doctor.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#9I 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…
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…
Oh absolutely, especially in an emergency. I mentioned the other scenario because when I've told this story before people have been skeptical that a bedside provider could make that kind of error.
Re: VA staff flag dangerous errors in Oracle-built electronic health record
#10I'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? Clone whatever other state system is the best. VA needs a system for hospital records? Don't develop from scratch, start by cloning the best system you can find amongst the thousands of existing hospital networks, and customize from there.