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Computers Wouldn’t Have Helped in Overdoses of Texas Babies

Friday, July 11, 2008 - 10:12
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After 17 babies got overdoses of the blood thinner heparin at a Texas hospital, a hospital-quality group pointed to the incident as one more reason to push for computerized systems for ordering drugs within hospitals.

The call to action invoked one of the health-care buzz-phrases of the moment: computer physician order entry, or sometimes automated physician order entry. It means doctors give their orders electronically, instead of verbally or by scrawling instructions on paper. The idea is to reduce errors and complications. Computers can also check automatically for drug interactions, implausible doses and more.

There’s just one problem in this case: automation wouldn’t have done much for the tots in Texas. A pharmacist made an error mixing heparin solution, often used to flush IV lines — and IV flushes often aren’t part of physician orders anyway. You can read the statement from Christus Spohn, which also says there’s no indication as yet that heparin contributed to the deaths in the NICU.

Doctors typically prescribe a dose of a particular drug over a particular time, and whether it should be administered intravenously or by mouth, for example. But a pharmacist often decides just how the drug will be prepared, whether by syringe into an IV or pre-mixed with saline. The pharmacist may note that a heparin flush is indicated before and after administration, or the nurse may know that it’s just part of the standard procedure.

“You wouldn’t order a tongue depressor to do a physical – you’d just expect it to be there,” says Dennis Tribble, a 30-year hospital pharmacist and chairman of the pharmacy-informatics section of the American Society of Health System Pharmacists. “There are lots of good reasons to be a strong proponent of computerized physician order entry. It simply doesn’t solve this problem.”

CPOE might not have prevented the infamous overdose of actor Dennis Quaid’s twinseither. That happened when a medication cabinet contained vials of heparin a thousand times stronger than the sort that should have been there.

Another up-and-coming technology might have helped the Quaids, but not the Texas tykes: Bar Code Medication Administration, or BCMA. Those systems require medications to be labeled with bar codes in the pharmacy identifying drug, dose and patient, and then checked — via scanner and computer — against codes in the medical record and a patient armband. But if the wrong dose is mixed and mislabeled in the pharmacy, overdoses can still occur.

“There still is that interface of human to computer that is always going to be plagued with problems,” Zachary Stacy, an associate professor at the St. Louis College of Pharmacy, tells Health Blog.

But the ultimate value of CPOE lies in the hospital’s complete reevaluation of its operations, says Leah Binder, CEO of the Leapfrog Group, who linked the Texas overdoses with CPOE in a statement. “Like any software and hardware, you don’t just put it on a shelf and turn it on,” she told the Health Blog. “It forces you to think systematically about how medications are administered.”

Low-tech safeguards also exist, of course. States require at least one other person to check medications filled in hospital pharmacies. Stacy says his hospital, St. Luke’s, requires techs to keep the empty vial the drug came in next to the saline bag it was mixed into, until a pharmacist can check that the right drug and amount were used. Similar-sounding drugs may be stored at opposite ends of the pharmacy to force technicians to think about which they want.

High-tech solutions are emerging as well. Big hospitals may have a robotic system that automatically mixes the ordered dose and proportions — as long as the orders were enetered correctly and the right compounds are stored in the right places. Tribble is co-founder of ForHealth Technologies, which markets a system to track and photograph pharmacy techs as they mix doses, letting the tech or a pharmacist review what they’ve actually done after the fact.

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