In the august British Medical Journal of April, 21, 2007 an article entitled LESSON OF THE WEEK: Information technology cannot guarantee patient safety appeared. The article was by Saskia N de Wildt, Ron Verzijden, John N van den Anker, and Matthijs de Hoog and the reference is BMJ 2007; 334: 851-852. (doi: 10.1136/bmj.39104.625903.80)
The article provided commentary on the following case report:
“A 3 month old infant who arrived at the emergency department of a small regional hospital had clinical signs of meningococcal sepsis with petechiae, purpura, and shock. The infant was subsequently transferred to our paediatric intensive care unit. During transfer the patient was given infusions of dobutamine and noradrenaline by the transferring intensivist. The concentrations of 12 drugs that might be needed for infusion during transport had previously been calculated in the intensive care unit by the resident. This had been done by entering the patient’s weight into a preprogrammed PocketExcel sheet for a personal digital assistant (handheld computer).
When the patient arrived at the unit all running drugs were ordered using our electronic patient data management system (a bedside computer application). This system uses the patient’s weight and the desired infusion rate to calculate concentrations of solutions for infusion. However, the concentration of noradrenaline calculated was sevenfold lower than that calculated previously, so that the patient had received a sevenfold higher dose of this drug than intended for at least two hours.”
In simple terms what had happened was that a spreadsheet based drug dosage calculator had been found to have misled a tired resident at 4.00am in the morning. The reason this was possible was that a simple spreadsheet running on a hand held computer was used and the spreadsheet did not have functionality to ensure constants were not overwritten and the child’s weight was entered into the wrong column.
On the basis of this the article concludes – as indicated in the title – that “Information Technology Cannot Guarantee Patient Safety” I could equally validly conclude that amateur spreadsheet authors should not be permitted to program computing tools they did not fully understand or even that doctors should be compelled to use pencil and paper to calculate drug dosage regimens.
William T Stevenson, a Consultant Radiologist of the Royal Lancaster Infirmary LA1 4RP gets it oh so right in a letter to the editor stating:
“Pretty soon we can expect a Lesson of the Week emphasizing that it's a bad idea to remove the wrong kidney.
The point here is that if a bunch of zombies (presumably members of the group who believe that information from the Internet must be reliable, that walking along the street engrossed in a mobile phone is an activity worthy of a sentient being and that counselling and mentoring are good ideas) are permitted to entrust all responsibility for a simple calculation with a potential deadly effect to a calculator, things are apt to go wrong.
It is a truth universally acknowledged that people who operate on hearts know which way the blood goes round; people who wish to inject dangerous drugs are expected to be able to find out how much to inject. They are not permitted to claim "I was never any good with figures"-if that's too tough they need to look for a job in Ethics or something.
You take a piece of paper, round the numbers to integers, get the powers of 10 correct, and get the rough answer. Then see if it's reasonable. Then use the calculator, spreadsheet or supercomputer, if you can't rid yourself of the delusion that the more decimal places the better. Surely the combination of A-levels, years at medical school and MMC can achieve this without pleading that we are helpless victims of those terrible computers.
Isn't the Public entitled to expect that a little thought has gone into 'fail-safing' these systems, in view of the inevitable failure of components? I suggest a little notebook with writing in it. “
For a major, refereed clinical journal to publish such an article just leaves me speechless and plays to the prejudice of the one or two Luddite practitioners who are still out there and seem to be found within the walls of the BMJ editorial offices.
The BMJ and its editors are guilty of the most amazing logical over-reach I have seen in years and are to be condemned for their stupidity.
This said, of course any computer program that is used in clinical care delivery needs to be robustly tested before deployment and the use of facilities such as range-checking and so on are vital – as is usability and safety testing to ensure safe program operation. The lesson here, if there is one, is that any programs used to support clinical care delivery need to be professionally and responsibly evaluated both for clinical and technical safety before deployment. Creation of such tools is not something to be done by enthusiastic but technically limited amateurs who do not appreciate the possible risks they run.
David.
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