Patient Safety Tip of the Week
June 19, 2007
Unintended
Consequences of Technological Solutions
In our April 2, 2007 Tip of the
Week we showed an example about how a technological advance (a dual-power
source portable ventilator) gave rise to an unintended consequence. It is not
at all uncommon for technological advances to create some new unintended
consequences.
In the early days of telemetry,
hospitals realized they could now utilize remote telemetry to free up valuable
ICU beds. A hospital purchased such a remote telemetry system in which the
transmitter could be placed on a patient on one floor of a hospital and the
receiver/monitor was in the CCU as part of a bank of telemetry screens that
were continuously viewed by a nurse assigned to that duty. One day, right
around nursing change of shift, two patients were admitted to the remote floor
and telemetry was ordered on both. The nurse took two transmitters with him and
hooked the patients up, then called the CCU monitoring nurse to tell her about
the two patients just hooked up. About an hour later the CCU monitoring nurse
called the remote floor because one of the patients was in ventricular
fibrillation. A code was called and the floor staff and code team ran to the
patient’s room, only to find him sitting in bed, watching TV and eating a meal.
Only after several minutes of fiddling with his EKG leads and talking to the
nurse in the CCU did anyone realize that the patient several rooms down the
hall was really the one in ventricular fibrillation. The transmitters obviously
had been transposed! This is a variation of the “two in a box” phenomenon we
talked about in the April 23, 2007 Tip of the Week. And, of course, the system
was poorly designed in that it allowed the first nurse to take out two remote
telemetry transmitters at the same time. However, we are presenting it here as
an example of how a technological solution expected to enhance patient safety
actually created a new unintended problem.
Another example was when a hospital
purchased a new alarm system that would send an alarm when the patient got out
of bed. It turned out that on some units there were not enough electrical
outlets for both the new bed alarms and the nurse call buttons. So a decision
was made in some cases to swap out these two devices. You can guess what
happened: nursing staff responded to the “out-of-bed” alarm only to find the
patient lying on the floor with an injury because he tried to get out of bed
after no one responded when he pushed the nurse call button!
And there are lots of examples of
unintended consequences associated with CPOE (computerized physician order
entry). The classic example is correction of the illegible handwriting
problem but introduction of the “cursor error” or “stylus error” in which
the physician inadvertently chooses a medication above or below the one he/she
actually intended to choose on the computer or PDA screen. The last issue of
ISMP’s newsletter had an example of a nonventilated patient inadvertently being given a paralytic agent,
in part because the ordering physician was entering orders from a remote site
and accidentally ordered this for the wrong patient.
We present these cases not to
discourage use of technology, which is one of our most potent weapons in the
patient safety arsenal, but rather to remind all that any solution (whether
technological or instituting a new approach, etc.) may give rise to unintended
consequences. Sometimes they can be anticipated, other times they cannot.
Either way, careful vigilance for unintended consequences is necessary.
Update: See also May 20,
2008 Patient Safety Tip of the Week “CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?”
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