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I once flagged a bug in Epic, the big EHR system. The system had somehow mixed up kilograms and pounds. For example, a normal adult male weight of 150lbs would
by cratermoon 11mo ago
I once flagged a bug in Epic, the big EHR system.
The system had somehow mixed up kilograms and pounds.
For example, a normal adult male weight of 150lbs would be ~68kg,
But accidentally save it without converting and get 150kg.
Convert back and it becomes 330lbs.
Suddenly our reasonably slim man becomes grossly obese.
It's not just wrong,
it's extremely dangerous.
In an emergency situations,
where morphine is commonly administered for extreme pain,
the dosage needed to relieve the pain of a 330lb man would kill a 150lb man.
Granted the responder at the patient's side would probably realize something is amiss,
but a pharmacist in another room filling an order wouldn't have the context,
and could make the error.
- jermaustin1 11mo agoI wouldn't trust that a nurse or doctor that is bedside to flag that either, though. Hospitals are woefully understaffed, and while they will do there best, we are all just humans. My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it. There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested. Too many patients, too few doctors, and with Epic, too many button clicks.
- skeptical_md 11mo agoI am very sad to hear that your grandmother died as a result of a medical error, but the details of the story as you remember them aren’t quite plausible. 1) Metformin is not available in an IV formulation 2) Metformin itself is not nephrotoxic It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.
- daveguy 11mo agoI expect GP mistook metformin-associated lactic acidosis in a patient with kidney disease as something metformin-caused. A separate but coincident IV misadministration could be an exacerbating factor. It would have been a rare case, but a plausible explanation for the misunderstanding. Metformin is relatively kidney safe and not administered by IV. Thank you for clarifying that for anyone that may currently on or considering Metformin. It would be great if medical professionals were infallible communicators and had time to verify understanding, but they are human and we need more doctors and less time-pressure by profit extracting private equity. Disclaimer: I am not a doctor.
- BobaFloutist 11mo agoAlso even when medical professionals communicate flawlessly, they're communicating to non-professionals who will necessarily encode their understanding in an imperfect mental model that will likely degrade over time.
- jermaustin1 11mo agoI'll defer to your expertise. I wasn't there, and just sharing what aunt was "told".
- cratermoon 11mo agoI don't see any mention of IV in the OP comment.
- moioci 11mo agoIt says the second dose was "injected."
- cratermoon 11mo agoyeah, you can do that with needle and syringe.
- cratermoon 11mo agoOh absolutely, especially in an emergency. I mentioned the other scenario because when I've told this story before people have been skeptical that a bedside provider could make that kind of error.
- malcolmgreaves 11mo agoDamn, sorry to hear that a nurse killed your grandma :(
- kotaKat 11mo agoWired covered the story twelve years ago of an Epic implementation failure that led to a child’s overdose (and recovery), of note: https://www.wired.com/2015/03/how-technology-led-a-hospital-to-give-a-patient-38-times-his-dosage/ https://www.wired.com/2015/03/how-technology-led-a-hospital-... https://archive.is/1QPmK https://archive.is/1QPmK
- epcoa 11mo agoOpioids are not weight based dosed for adults. Typically pain protocols start at fixed doses based on prior opioid use and titrate up for effect. Also was this a bug in Epic proper or a site specific customization?
- cratermoon 11mo agoOK, so my example is flawed, but the scenario remains valid. I was going off charts like https://nursing.duke.edu/sites/default/files/documents/SCD-Opioid%20Weight%20Based.pdf https://nursing.duke.edu/sites/default/files/documents/SCD-O... I don't know anything about the bug other than my provider who I'd communicated and demonstrated the behavior to came back to me confirming that it was a real bug and was being fixed.
- harvey9 11mo agoIn emergency situations (or even routine ones) where I'm administering morphine, I don't need a computer to help me figure out the dose. There are more complex dose calculations where good tech matters far more. Harold Thimbleby has some very accessible talks on safety in health tech: https://www.youtube.com/watch?v=AobMb3S5OtY&t=1034s https://www.youtube.com/watch?v=AobMb3S5OtY&t=1034s
- cratermoon 11mo agoI suppose I'd better change my example to something that is more dependent on accurate weight. I do know that at one point there were weight/dose charts for morphine administration, e.g. https://nursing.duke.edu/sites/default/files/documents/SCD-Opioid%20Weight%20Based.pdf https://nursing.duke.edu/sites/default/files/documents/SCD-O... but that could be an outdated practice.
- harvey9 11mo agoThe calculation charts are valid but you can give it slowly and stop at whatever dose the patient reports good effect. I do highly recommend Prof Thimbleby's talks in this topic.
- cratermoon 11mo agoThank you, I'll give them a look.