alt Hacker NewsI 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.
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In 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
Opioids 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?
Wired 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-... https://archive.is/1QPmK
I 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.