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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

Genesis emerged from a heart operation on Oct. 15 without any clear complications, said the Burketts’ attorney, Patrick Salvi. Yet later that day, Fritzie Burkett said she got a call from the hospital telling her to come in immediately. When she arrived, Burkett said, medical staff were performing CPR on Genesis, and about 40 minutes later they pronounced him dead.

“I lost all self-control; I didn’t know what to do,” Burkett recalled.

Dr. Lee Sacks, chief medical officer for Advocate Health Care, the Chicago area’s largest health care system, said the hospital’s investigation revealed that a pharmacy technician had entered information incorrectly when processing an electronic IV order for the baby, resulting in a massive sodium chloride overdose in the solution.

The problem could have been identified by automated alerts on the IV compounding machine, but those were not activated when the customized bag was prepared for the baby, according to the hospital. Asked why, Sacks cited ongoing litigation and declined to elaborate.

Advocate’s investigation also found that the outermost label on the IV bag administered to the baby didn’t reflect its actual contents, Salvi said. And while a blood test on the infant had shown abnormally high sodium levels, a lab technician assumed the reading was inaccurate, Salvi added, citing the hospital’s investigation.

Still another issue that played a role in baby Burkett’s death was a communication gap between the hospital’s electronic ordering system and the machine that prepared his IV fluids.

Almost all medication requests at Advocate are transmitted by a doctor’s keystroke to the hospital pharmacy’s drug-dispensing system. But in this case, there was no electronic connection with the automated compounding system that prepared the IV bag for baby Burkett, a specialized device that handles low-volume, highly individualized orders.

So, a technician transcribed the order by hand and an error was introduced.

Electronic communication gaps are common at large hospitals, which typically use upward of 50 to 100 different information systems at their facilities, with different technologies used in emergency rooms, labs, pharmacies and other medical departments, said Ross Koppel, a sociologist at the University of Pennsylvania who studies health information technologies.

“To some degree these systems talk to each other, but mostly they don’t, so hospitals have to design custom-made software ‘bridges’ to make this happen,” Koppel said. With each jury-rigged software solution comes the potential for new software bugs, transcription errors and other problems.

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