Computer Flaws Cause Dangerous Hospital Errors

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A popular hospital computer system raises the risk of 22 different – and potentially deadly – drug-prescribing errors, research shows.

The most common source of hospital errors comes when doctors prescribe drugs for a patient. Mistakes can be deadly. That's why most hospitals bought computer systems designed to make sure patients don't get the wrong drug, at the wrong dose, at the wrong time.

But the most widely used hospital computer system actually adds to the risk of medication errors, a new study shows. University of Pennsylvania researcher Ross Koppel, PhD, and colleagues report the findings in the March 9 issue of The Journal of the American Medical Association.

"That [computerized drug-ordering system] use might increase the likelihood of medication errors was an unanticipated finding," Koppel and colleagues write. "Several [computer]-enhanced risks appear common (that is, observed by 50 to 90 percent of house staff) and frequent (that is, repeatedly observed to occur weekly or more often)."

The researchers don't blame any particular computer system. Instead, they say, the problem is that hospital computer systems are not designed for the way real-life hospitals work.

Types of Hospital Errors Linked to Computer System

Koppel's team looked at only one hospital, but it was a long, hard look. They surveyed 261 staff members of a major urban hospital and conducted five focus groups and 32 intensive one-on-one interviews. They also shadowed doctors and nurses as they used the hospital's computer system in their daily work.

Examples of ways the computers increased error risk included:

--The computer system warned doctors that a patient had a drug allergy only after the drug was ordered.

--To order just one drug, a busy doctor might have to page through 20 screens of information.

--Contrary to what many doctors thought, the computer didn't show the minimal effective or usual doses of particular drugs. Instead, it showed the dosages available in the hospital pharmacy.

--Drugs are often prescribed for certain procedures or tests. But if these procedures were canceled, the drugs weren't automatically canceled.

--If the computer system shut down when a patient was moved within the hospital, that patient's drugs were sent to the wrong room.

Technical Solutions for Social Problems Create Errors

Accompanying the study is an editorial by Robert L. Wears, MD, of the University of Florida, Jacksonville, and Imperial College, London; and Marc Berg, MD, PhD, of Erasmus University, Rotterdam, Netherlands.

"Rather than framing the problem as 'not developing the systems right,' these failures demonstrate 'not developing the right systems,'" Wears and Berg write.

Designers of computer systems make a basic mistake, they argue. They see hospital errors as a technical problem. But hospitals are worlds in which real people interact with each other as well as with technology.

"An information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive," Wears and Berg conclude.

By Daniel J. DeNoon, reviewed by Brunilda Nazario, MD

SOURCES: Koppel, R. The Journal of the American Medical Association, March 9, 2005; vol 293: pp 1197-1203. Wears, R.L. and Berg, M. The Journal of the American Medical Association,March 9, 2005; vol 293: pp 1261-1263.