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Baby's Death Spotlights Safety Risks Linked to Computerized Hospital Systems

Baby's Death Spotlights Safety Risks Linked to Computerized Hospital Systems

Chicago Tribune

CHICAGO _ The medical error that killed Genesis Burkett began with the kind of mistake people often make when filling out electronic forms: A pharmacy technician unwittingly typed the wrong information into a field on a screen.

Because of the mix-up, an automated machine at Advocate Lutheran General Hospital prepared an intravenous solution containing a massive overdose of sodium chloride _ more than 60 times the amount ordered by a physician.

When the nutritional fluids were administered to Genesis, a tiny baby born 16 weeks prematurely, the infant’s heart stopped and he died, leaving behind parents stunned by grief to this day.

Although a series of other errors contributed to the tragedy, its origin _ a piece of data entered inaccurately into a computer program _ throws a spotlight on safety risks associated with medicine’s advance into the information age, a trend being pushed aggressively under health reform.

The federal government is aiding the shift with $23 billion in incentives to medical providers who buy electronic medical records or computerized systems that automate drug orders and other medical processes. The hope is that these technologies will enhance access to vast amounts of information now tucked away in paper files and meaningfully improve medical care.

Doctors should be able to see test results quickly and communicate more easily with each other, for example. And electronic safeguards also can remind physicians about recommended medical practices or alert them to harmful interactions between medicines.

Yet with these sizable potential benefits also come potential problems. Hospital computers may crash or software bugs jumble data, deleting information from computerized records or depositing it in the wrong place. Sometimes, computers spew forth a slew of disorganized data, and physicians can’t find critical information about patients quickly.

Meanwhile, different electronic systems used in hospitals may not be able to communicate, and the alerts built into these systems are often ignored because they are so frequent and often are not especially useful, physicians and other experts report.

Technology vendors tend to dismiss incidents like the death that occurred at Advocate Lutheran General in Park Ridge as arising from human errors, not product deficiencies. But other experts say health information technologies can lead to mistakes when they aren’t in sync with the way medical providers work.

“We see problems much more often than we would like” because many health information systems are poorly designed and difficult for doctors and nurses to use, said Dr. Rainu Kaushal, chief of the division of quality and medical informatics at Weill Cornell Medical College in New York City.


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