Healthcare Software

EMR Usability at the Root of Many Medical Errors

The FDA has called out to healthcare providers to report problems with EMR software in response to concerns over patient safety. It is reported that there are 260 examples of “malfunction” in healthcare IT software in the past 2 years, but what is at the root of these problems? Is it really the software at fault or is it something else? The FDA letter refers to 3 examples of failure in software that put human lives at risk.

These examples are:

1. Emergency room software returned the lab test results of the wrong patient. The software was being used to prescribe medications.
2. Operating room software locking up during surgery leading to incomplete surgical procedure data and necessitating manual data entry from memory after the procedure.
3. Radiology workstations suffering application performance problems (because of a misprocessing of long input strings) leading to patients having to retake X-rays.

While these examples given are genuine software implementation errors, many of the others entered into the FDA’s MAUDE Adverse Effects database are not. In fact, after examination, a lot of them are software usability problems as reported in this article. It is interesting to read some of these issues in their raw form and see how usability issues affect the performance of healthcare providers.

Some of the more succinct examples (with report numbers in parentheses) are:

1. CERNER MILLENIUM CPOE, POWERCHART (MW5014371). The displays, formats, layouts, and interfaces of the cpoe tools at this institution contain elevated degrees of user unfriendliness. This toxic effect on the user is manifested by, to mention a few, more than 20 electronic silos in which orders are stored and extensive wordiness using descriptors that are highly irrelevant to the task of the care of pts with critical illness. This manifests itself in several ways, one of which is the ordering of duplicate medications and treatments, some of which get to the pt. These should be reported to pharmacopoeia data bases but often are not. This pt was being infused both total parenteral nutrition and a concentrated dextrose solution, the combined rate of which and cumulative dose caused pulmonary edema.
2. CERNER MILLENIUM CPOE (MW5014300). Electronic order entered in to the cpoe contrivance ordering the holding of sliding scale insulin at night time. The order was delivered to an electronic file on the nurse's module. This order was not seen by the nurse. Insulin was given. Hypoglycemia with severe symptoms ensued. Orders are delivered without notification to electronic files of the nurse's module. There is a design flaw consisting of failures of the contrivance to link free text orders to specific treatments and medications and to notify health care professionals of new or stat orders. User error is invariably extended as cause to cover-up the design defect facilitating such error.
3. SIEMENS MEDICAL SOLUTIONS, SIEMENS PHARMACY SOFTWARE (1691454). The pharmacy medication alert system was updated and the alerts were inadvertently turned off. The alerts were down for approximately 7 days.
4. GE HEALTHCARE, PACS SERVER (3004526608-2010-00006). The customer reported that the technician entered the date of birth (b) (6) instead of the study date of (b) (6), making the report appear older than what it was. The radiologist was viewing the images for pic line placement and the comparison film did not have the line present. When the film did not have the line present, the radiologist assumed the line had been removed, not verifying proper placement. The baby, who was pre-mature, died. The risk manager stated that the line was inserted too far, which contributed to the death, though not certain it caused the death. The risk manager also stated that they consider the incident a "work process error" and not a malfunction of pacs.
5. PHILIPS STENTOR PACS (MW5015614). Pt with chief complaint of shortness of breath. Cta of chest, abdomen, pelvis was ordered. Report sent was that of a mri of the spine, despite the ordered test being listed on the report as "cta chest abdomen pelvis". Misidentification is the general category of defect though there is commingling of data divergent with the listed test. It is unk by this reporter if this was part of a recursive process affecting innumerable pts.

It is relatively simple to get access to the rest of the entries. This page details how to best use the MAUDE database for online search.