A 39-fold overdose of Septra: how EHRs can threaten patient safety

Robert Wachter bobw@medicine.ucsf.edu

Abstract

In 2013, a 16-year-old patient at UCSF was given 39 Septra (a common antibiotic) tablets, instead of the one he should have received. He suffered a grand mal seizure and spent 10 days in the intensive care unit as a result. This error is all the more remarkable because it occurred in one of America's top hospitals, despite – check that, because of – state of the art computerized order entry and bar coding systems. The error is described in my new book, "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age," which will be published in April and has already had pre-launch sales of approximately 10,000 books. In the presentation, I will describe this remarkable case and how problems such as alert fatigue, poor user interfaces, and overtrust in technology open up the opportunities for new kinds of harm. The presentation will end by discussing what can be done – both in terms of improving IT systems and also changing practice and culture – to make health IT safer.

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