In 2013, a patient admitted to Northwest Community Hospital in Arlington Heights, Ill., did not receive his previously prescribed psychiatric medicine for nearly three weeks during a hospital stay because the pharmacy’s computer system was programmed to automatically discontinue orders for certain types of drugs after a predetermined time.
Recent studies have found that rapid implementation of new medical technology-electronic health records, patient monitoring devices, surgical robots and other tools -can lead to adverse patient events when it is not thoughtfully integrated into workflow.
Over the past year, the MedStar team has evaluated dozens of devices, including health IT software, infusion pumps, patient beds and wound-treatment devices, among others.
The digital device read: “Critical Value, Repeat Lab draw for >600.,” which seemed to indicate the patient’s blood sugar was critically high.
The patient’s blood sugar was actually extremely low, and the resulting erroneous treatment sent the patient to the ICU.
He decided the patient’s heart was in distress and ordered a synchronized shock to be delivered at a low level using a defibrillator, a process that helps re-establish normal heart rhythms in a patient with an arrhythmia or in cardiac arrest.
The nurse pushed a button to put the device into synchronized shock mode so the energy would hit the patient’s chest at a less-vulnerable moment for the heart.
Source: http://www.modernhealthcare.com/article/20140816/MAGAZINE/308169986
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