Need a medicine in hospital? Our study shows how often IT failures lead to the wrong medicine or dose

Each time a medication is prescribed in the hospital, the computer will inform the doctor whether the medication is appropriate and what dose to prescribe.

Each time a healthcare provider updates a patient’s medical record on a computer, they must enter the appropriate information in the appropriate space or select an option from a drop-down menu.

But as a growing group research showsthese electronic systems are not perfect.

Our new study shows how common these technology-related errors are and what they mean for patient safety. They often occur because of programming errors or penniless design and have less to do with the healthcare workers using the system.

What were we looking at? What did we find?

Our team analyzed more than 35,000 medication orders at a enormous urban hospital to understand how common technology-related errors were.

We focused on errors made when prescribing or ordering medications through a computer system. In many hospitals, these systems have replaced the clipboard that hung at the end of the patient’s bed.

Our research has shown that up to one in three medication errors is technology-related. This means that the design or functionality of the electronic medication system facilitated the error.

We also analyzed how technology-related errors changed over time by examining error rates at three time points: the first 12 weeks of system exploit and one and four years after implementation.

We can expect technology-related errors to become less constant over time as healthcare workers become more familiar with the systems. However, our research has shown that while there is an early “learning curve”, technology-related errors remained a problem for many years after the implementation of electronic systems.

In our study, the rate of technology-related errors was the same four years after system implementation as in the first year of exploit.

How can errors occur?

Errors can happen for many reasons. For example, prescribers may be faced with a long list of possible doses of a drug and inadvertently select the wrong one. This can lead to a dose that is lower or higher than intended.

In our study, we found that high-risk medications were often associated with technology-related errors. These included oxycodone, fentanyl, and insulin, all of which can have solemn side effects if prescribed incorrectly.

Technology errors can occur at any stage of patient care when using a computer.

One case in the United States, a nurse accessed and administered the wrong medication. The medication was taken from a computer-controlled dispensing cabinet (known as an automated dispensing cabinet) that is used to store, dispense, and track medications.

Due to penniless design, the cabinet allowed the nurse to search for medications by typing in only two letters. A good design would not have displayed any medication options with only two letters.

A nurse selected and administered the wrong medication to a patient, which caused cardiac arrest and the nurse faced criminal charges.

Automatic dispensing cabinets are used more and more often rolled out in Australian hospitals.

Earlier this year we heard about an error in the electronic health records system in South Australia. the payment deadline was calculated incorrectly in more than 1,700 pregnant women, which may result in premature induction of labor.

We produce a series Security Bulletins for the healthcare system, which describe and address specific examples of penniless system design that we have identified during our research or that have been brought to our attention by others working in the system.

These include a drop-down menu that allows you to prescribe medication via spinal injection. This particular medication would be fatal if served this way.

Another one shows built-in calculator which rounds up or down medication doses according to established rules. However, this can lead to incorrect doses in very newborn or low-weight children.

We provide recommendations for optimizing systems with each example. Organizations can then exploit these specific examples to test their systems and take action.

What else could improve security?

As digitalization increases in our hospitals and healthcare, the risk of technology-related errors increases. And that’s before we even start talking about the potential for error in the AI ​​used in our healthcare systems.

We are not calling for a return to paper records. But until we take on the task of making computer systems secure, we will never fully realize the enormous potential that digital systems can provide in healthcare.

Systems need to be constantly monitored and updated to make them easier and safer to exploit and to prevent disasters.

Healthcare IT managers and developers must understand errors and recognize situations where the system design is suboptimal.

Because physicians are often the first to notice problems, mechanisms should be in place to quickly investigate and address their concerns, supported by systematic data on technology-related errors.