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I believe this is a good example of the "Swiss Cheese Model" of safety incidents (see below).
At our hospital, we have had a few near disasters relating to the CPOE. Once, during a severe post-partum hemorrhage, the nurse couldn't get the appropriate medicine out of the machine because they had just switched from using a fingerprint ID system to a password ID system. She had been assigned a password, but either forgot it in panic, or never actually received it yet. There have been other similar cases.
The current system really underestimates the role of the nurses as first responders in the hospitals in a crisis. They save patients and physicians' asses on a routine basis. In an emergency, nurses should have "root" access to the CPOE. If bean counters saw a woman with a post-partum hemorrhage spraying blood like a broken faucet, they would understand.
James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps [1-5]. According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese. These weaknesses are inconstant – i.e., the holes open and close at random. When by chance all holes are aligned, the hazard reaches the patient and causes harm (Figure 1). This model draws attention to the health care system, as opposed to the individual, and to randomness, as opposed to deliberate action, in the occurrence of medical errors.
The Swiss cheese model is frequently referred to and widely accepted by patient safety professionals. This was summarised by safety expert Ronald Westrum in a testimony before a United States Advisory Committee on Blood Safety and Availability on April 25, 2000 [6]:
Matthew M. King, MD Medical Director Clinica Adelante, Inc Surprise, Arizona 85374 [EMAIL PROTECTED]
-----Original Message-----
I have just seen a copy of the article and I hope it will be available online, perhaps in January.
There were multiple changes made in the work-flow at the time CPOE was rolled out. Prior to the implementation, critically ill children would have orders written before their arrival so medications, and the setup for tests might be available and at the bedside before the child's arrival. Afterward, everything had to be ordered online after the child's arrival and this was not as fast as the hand written orders. As a result of the problems, changes were later made to allow more flexibility.
So it seems most likely that it was not the program itself causing the problems.
On Monday 05 December 2005 06:09 pm, Carroll, Richard (EDS) wrote: Could this rise come from a lack of field training, a failed installation step or procedure, or good old human error and this is just a wrinkle in the probabilities. Given the option, I try to charge errors to accident rather than malice.
If this rise of pediatric ICU mortality is the direct result of physicians writing orders which kill patients while their reckless malpractice goes ignored, then why are they suddenly writing these orders in increasing numbers? Why the rise in ped ICU? Some physician consperacy to lower the population?
This is why it's a good thing to read the article before making up our minds. After all, it seems they have made a reasonable request in the meantime:
'...Although CPOE technology holds great promise as a tool to reduce human error during health care delivery our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.'
Ric
-----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Ruben Safir Sent: Monday, December 05, 2005 4:26 PM Subject: RE: [Hardhats-members] Increased Mortality after CPOEImplementation
On Mon, 2005-12-05 at 17:18, Carroll, Richard (EDS) wrote: > Is it not possible that patients might be at risk and even die from a > delay in the administration of oral and/or IV medications that were > properly ordered by physicians? It appears suspicious to me that the > mortality went up after the implementation of a new CPOE system...
It is IMPOSSIBLE for that to have been the fault of the software, especially if the ADR's are going down.
Its HIGHLY unlikely that this would cause a higher mortality under ANY condition other than the ICU.
Ruben
> Ric > > -----Original Message----- > From: [EMAIL PROTECTED] > [mailto:[EMAIL PROTECTED] On Behalf Of > Ruben Safir > Sent: Monday, December 05, 2005 4:06 PM > To: [email protected] > Subject: Re: [Hardhats-members] Increased Mortality after > CPOEImplementation > > Actually, in this case, i don't need to read the article. Blaming > Physician based order entry for an increase mortality rate is on its > face a stupid as prayer to the growth rate of house plants. > > The only reason for an increase in mortality can only be because > Physicians are writing orders which kill more patients while the rest > of the institution ignores their recklessness. It wouldn't surprise > me if this was a direct result of the political wrangling involved > with such implementations which often result in the cutting the balls > off of the Doctors in the Pharmacy, not to mention other checks and
balances.
> Ruben > > On Mon, 2005-12-05 at 16:48, Nancy Anthracite wrote: > > The Journal of Pediatrics is unusual in that it often allows full > > text > > > > viewing of thier articles online. Unfortunately, the November issue > > > > is the latest one posted, but by January we could possibly all be > > able > > > > to read it and judge for ourselves. I will send a note on to > > someone active in the ACP to see if perhaps that could be one of the > > > > free > > articles. > > > On Monday 05 December 2005 04:33 pm, Ruben Safir wrote: > > In fact, this sounds like a case where the health care facility > > ignores its pharmacists, causing an increased death rate. > > > > Ruben > > > > On Mon, 2005-12-05 at 15:16, Ignacio Valdes wrote: > > > The December 2005 issue of the journal Pediatrics has a report > > > that found a coincident increase in mortality after implementing a > > > > > > 'Commercially Sold' Computerized Physician Order Entry (CPOE) > > system. > > > > The increased mortality may have been due to delays in medication > > > and IV administration in the ICU caused by the new system: > > > '...Although CPOE technology holds great promise as a tool to > > > reduce > > > > > > human error during health care delivery our unanticipated finding > > > suggests that when implementing CPOE systems, institutions should > > > continue to evaluate mortality effects, in addition to medication > > > error rates, for children who are dependent on time-sensitive > > > therapies.' The study notes that mortality rate studies on CPOE as > > > > > > opposed to adverse drug > > > events(ADEs) studies has not been done before. The CPOE in the > > > study > > > > > > DID reduce ADE's as expected. > > > > > > Additional summary of the article here: > > > http://www.linuxmednews.com/1133812163/index_html > > > > > > > > > ------------------------------------------------------- > > > This SF.net email is sponsored by: Splunk Inc. Do you grep through > > > > > > log files for problems? Stop! Download the new AJAX search > > > engine that makes searching your log files as easy as surfing the
web.
> DOWNLOAD SPLUNK! > > > > http://ads.osdn.com/?ad_id=7637&alloc_id=16865&op=click > > > _______________________________________________ > > > Hardhats-members mailing list > > > [email protected] > > > https://lists.sourceforge.net/lists/listinfo/hardhats-members > > > > ------------------------------------------------------- > > This SF.net email is sponsored by: Splunk Inc. Do you grep through > > log > > > > files for problems? Stop! Download the new AJAX search engine that > > > > makes searching your log files as easy as surfing the web. > > DOWNLOAD > > SPLUNK! > > > http://ads.osdn.com/?ad_id=7637&alloc_id=16865&op=click > > _______________________________________________ > > Hardhats-members mailing list > > https://lists.sourceforge.net/lists/listinfo/hardhats-members > > ------------------------------------------------------- > This SF.net email is sponsored by: Splunk Inc. Do you grep through log > > files for problems? Stop! Download the new AJAX search engine that > makes searching your log files as easy as surfing the web. DOWNLOAD > SPLUNK! > http://ads.osdn.com/?ad_id=7637&alloc_id=16865&op=click > _______________________________________________ > Hardhats-members mailing list > https://lists.sourceforge.net/lists/listinfo/hardhats-members > > > > > ------------------------------------------------------- > This SF.net email is sponsored by: Splunk Inc. Do you grep through log > > files for problems? Stop! Download the new AJAX search engine that > makes searching your log files as easy as surfing the web. DOWNLOAD
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> http://ads.osdn.com/?ad_idv37&alloc_id865&opk > _______________________________________________ > Hardhats-members mailing list > https://lists.sourceforge.net/lists/listinfo/hardhats-members
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-- Nancy Anthracite
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- RE: [Hardhats-members] Increased Mortality after CPOE Im... Matthew King
- Re: [Hardhats-members] Increased Mortality after CP... Gregory Woodhouse
- Re: [Hardhats-members] Increased Mortality after CP... Gregory Woodhouse
- RE: [Hardhats-members] Increased Mortality after CP... Matthew King
- Re: [Hardhats-members] Increased Mortality afte... Gregory Woodhouse
- RE: [Hardhats-members] Increased Mortality after CP... Matthew King
- Re: [Hardhats-members] Increased Mortality afte... Kevin Toppenberg
