I was recently informed of a situation in which a high alert medication was programmed incorrectly, causing a gross rounding error to occur. Certainly the system could have been checked more carefully before implementing the changes, but what about the physician, pharmacist, or nurse? In this case the physician missed the rounding calculation (although shown on the ordering screen below the ordered dose). The pharmacist, our medication expert in the hospital setting also checked the order in the EHR without question. Luckily the discrepancy was caught by a completely unrelated test order, or ADEs could have resulted. Have we become so trusting of what shows on a computer screen that we don't question the content?
The power of the suggestive mind is not new to humans. It helps us fill in the blanks on those fun crosswords and MadLibs, and with those difficult co-workers. However, when it comes to the power of suggestion in electronic health records, seeing what we want to see may potentiate errors. This lab order is always twice daily, why should I pay attention to it after ordering it 15 times? The TPN order has always defaulted to 2000ml, can't I just skip review of the field? On rotation, my students are informed of this critical vulnerability in the healthcare computing age. We must use our minds to be sure what we see in a computer, in a book, or on the news makes sense. In our profession, we cannot take the computer's word for it. After all, it was programmed by a human and we are all aware of our nature. As we continue to learn more about technology adoption in healthcare, we will become aware of these pitfalls. In the meantime, we must remain diligent and ever questioning.
The power of the suggestive mind is not new to humans. It helps us fill in the blanks on those fun crosswords and MadLibs, and with those difficult co-workers. However, when it comes to the power of suggestion in electronic health records, seeing what we want to see may potentiate errors. This lab order is always twice daily, why should I pay attention to it after ordering it 15 times? The TPN order has always defaulted to 2000ml, can't I just skip review of the field? On rotation, my students are informed of this critical vulnerability in the healthcare computing age. We must use our minds to be sure what we see in a computer, in a book, or on the news makes sense. In our profession, we cannot take the computer's word for it. After all, it was programmed by a human and we are all aware of our nature. As we continue to learn more about technology adoption in healthcare, we will become aware of these pitfalls. In the meantime, we must remain diligent and ever questioning.
