Re: [Hardhats-members] Increased Mortality after CPOE Implementation

[Gregory Woodhouse]

On Dec 6, 2005, at 9:16 AM, Matthew King wrote: 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.   Was it a matter of gaining access to a supply cabinet (Pyxis, or something similar)? === Gregory Woodhouse [EMAIL PROTECTED] "Prediction is difficult, especially of the future." --Niels Bohr