Baby's death spotlights safety risks
linked to computerized systems
The medical error that killed Genesis Burkett began with the kind of mistake people often make when filling out electronic forms: A pharmacy technician unwittingly typed the wrong information into a field on a screen.
Because of the mix-up, an automated machine at Advocate Lutheran General Hospital prepared an intravenous solution containing a massive overdose of sodium chloride — more than 60 times the amount ordered by a physician.
When the nutritional fluids were administered to Genesis, a tiny baby born 16 weeks prematurely, the infant's heart stopped, and he died, leaving behind parents stunned by grief.
Although a series of other errors contributed to the tragedy, its origin — a piece of data entered inaccurately into a computer program — throws a spotlight on safety risks associated with medicine's advance into the information age, a trend being pushed aggressively under health reform.
Errors in Laboratory Medicine
Types of preanalytical errors registered during the year 2000 at the Laboratory of San Raffaele Hospital.
The problem of medical errors has recently received a great deal of attention, which will probably increase. In this minireview, we focus on this issue in the fields of laboratory medicine and blood transfusion.
Our search revealed large heterogeneity in study designs and quality on this topic as well as relatively few available data and the lack of a shared definition of “laboratory error” (also referred to as “blunder”, “mistake”, “problem”, or “defect”). Despite these limitations, there was considerable concordance on the distribution of errors throughout the laboratory working process: most occurred in the pre- or postanalytical phases, whereas a minority (13–32% according to the studies) occurred in the analytical portion. The reported frequency of errors was related to how they were identified: when a careful process analysis was performed, substantially more errors were discovered than when studies relied on complaints or report of near accidents.
The large heterogeneity of literature on laboratory errors together with the prevalence of evidence that most errors occur in the preanalytical phase suggest the implementation of a more rigorous methodology for error detection and classification and the adoption of proper technologies for error reduction. Clinical audits should be used as a tool to detect errors caused by organizational problems outside the laboratory.