In 2013, a mother brought her 2-year-old child with a broken leg to Sinai Hospital's emergency department in Baltimore. She told the admitting nurse her toddler weighed 35 pounds. The nurse hand wrote “35” onto a form without noting whether it was in pounds or kilograms.
When the information was copied into the child's electronic health record, the software automatically interpreted the weight in kilograms—its default setting—or 77 pounds. The baby was prescribed more than twice the normal dose of a drug at discharge.
Only hours after she and her child returned home, the woman called 911. Her child had turned blue and slipped into a coma. Emergency medical technicians raced the child back to the hospital, where the child was revived and admitted, according to a report filed with the CMS.
The incident prompted the hospital to change its EHR system. Now all scales are set so weights can be measured only in kilograms, and the EHR is auto-populated with the proper figure. “We continuously and vigilantly evaluate our processes, procedures and equipment to ensure the highest level of safety for our patients,” said Barbara Epke, vice president of quality for LifeBridge Health, which owns Sinai Hospital.
Even the most enthusiastic advocates of health IT concede the proliferation of EHRs and other software has introduced new safety hazards into already complex healthcare settings. A 2011 Institute of Medicine report found poorly designed EHRs were causing dosing errors, failures to detect life-threatening illnesses and delayed treatments because of poor human-computer interactions or data losses. In some cases, the errors had led to serious injuries and deaths.