VA staff flag dangerous errors in Oracle-built electronic health record(washingtonpost.com) |
VA staff flag dangerous errors in Oracle-built electronic health record(washingtonpost.com) |
It's not just wrong, it's extremely dangerous. In an emergency situations, where morphine is commonly administered for extreme pain, the dosage needed to relieve the pain of a 330lb man would kill a 150lb man. Granted the responder at the patient's side would probably realize something is amiss, but a pharmacist in another room filling an order wouldn't have the context, and could make the error.
My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it.
There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested.
Too many patients, too few doctors, and with Epic, too many button clicks.
1) Metformin is not available in an IV formulation 2) Metformin itself is not nephrotoxic
It certainly is believable that a medical error caused kidney failure but it is very unlikely to have been caused by an incorrect second IV dose of Metformin.
https://www.wired.com/2015/03/how-technology-led-a-hospital-... https://archive.is/1QPmK
Also was this a bug in Epic proper or a site specific customization?
I don't know anything about the bug other than my provider who I'd communicated and demonstrated the behavior to came back to me confirming that it was a real bug and was being fixed.
> Scrapping the millennium: introduction of a health record in Sweden fails
> The introduction of a new, heavily criticized electronic journal system from Oracle in two Swedish health districts has failed spectacularly.
https://www.heise.de/en/news/Scrapping-the-millennium-introd...
I was aware of this VA project at the time, although I was no part of it. I knew it was going to take years and we basically had no competition. Shortly before I left the company we got a new CEO from Google (Health?). Now looking back this guy was probably brought specifically for preparing for the Oracle acquisition.
We were a team of 5. After the Oracle acquisition everyone left. That team basically disappeared. Three of my teammates left for another IT company in Kansas. Things must have gotten really tough after the acquisition.
Everything has to run as root.
All their scripts are Korn shell hacks from the 90s that have been carrier over.
Their god awful Kickstart scripts were written in stone even if you prove that there were better ways.
Cerner controlled the root password.
Cerner123!
They hard coded passwords with ROT13.
No wonder Oracle bought them.
One need only google "Oracle failure" or visit theregister.com to see a list of atrocities committed yearly by Oracle for ERP and Financial system implementation fiascos, buying Cerner for their EMR that was already bad to use could only make it worse. It's like bad and worse got together to make a baby, but what are your alternatives in the space? I never met an ERP that wasn't a mess, or the staff that tend to manage them. Oracle just keeps expanding, because why be a lesser evil?
If you work in the medical IT field, you have my condolences, and my best advice is don't. The only ones that win are the executives above their meat shields and the investors. If you have to visit one in the US, you also have my condolences, as you'll see first hand the product above commentary.
Let's say we design a "dangerous errors" system. What it's going to consist of is some "are you sure you want to do that" style popups, and some sort of error reporting system.
The error reporting system (human entered) is where it gets interesting. The real nasty errors dutifilly get reported, no choice. The nasty and/or embarrassing errors are not reported. You get some of what they call "virtue signalling" errors where a person may report themself and pat themselves on the back for it - small errors. And than finally, about 1-5% of staff, the sorts that don't belong in medicine, will use it as their personal vendetta machine, ham up, falsify, fictionalize stories written against whoever it was that crossed them that day. Every day.
There CAN be on honest fair reporting system in the absolute healthiest of work cultures, with trust i.e. if I disclose I did something wrong I am confident that I won't be in trouble (that also means nobody can character assassinate someone else who crossed them - they won't be in trouble). But medicine, it's the opposite of such a culture, viciously political, unethical interpersonal practices, obsession with preserving ones career, license, and legal exposure over the common sense best interests of the patients.
It almost makes sense that the only way to get a customer was to essentially lobby and force your way into a government contract for it, and it’s still an unmitigated disaster.
My heart goes out to those that are going to get fucked over by this piss-poor deployment and be actually, physically harmed by bad EMR decisions and implementation choices.
> The program launched in 2018 to replace the aging computer system used across VA’s health care network, which serves more than 9 million veterans, with an off-the-shelf product that could handle many of the same tasks: organizing important information including appointments, referrals, prescriptions and patient histories.
> David Shulkin, the secretary at the time, announced that VA would negotiate a contract to buy the records system from Cerner without competitive bidding. VA leaders said they selected the program because the Pentagon already had purchased a similar Cerner system for the military’s more than 700 hospitals and clinics.
One of the interesting things about this is that, from my perspective, VistA's sort of a mesh of servers rather than the hierarchy we might expect from a federal system. Perhaps that's because of the complex interplay between federal and state and local laws. But anyway, there's probably a "station" for VistA near you that serves your area, and that's very similar (though not identical) to the "station" in the next neighboring area/metropolis/state/whatever.
But weirdly it seemed like the plan to roll this out was to replace all of the functionality at a given VistA station, rather than to do a strangler fig sort of thing and work on supplanting VistA's functionality in a specific functional area (whether locally or nationally). I don't know if that's because of the aforementioned complexity of laws, or the complexity of how the system(s) is/are administered, or other reasons that would elude me.
It's, uh, it's a fun situation.
This has led to somewhat of an arms race where government workers desperately collaborate with contractors to find a way to sidestep or subvert the bid process and other contractors aggressively seek to inspect and enforce the process.
Developing in-house governmental talent, institutional knowledge, and capacity is of course strictly off the table, as it would reduce opportunities for private profit in basic government services.
I think the bigger problem is that we're not meaningfully grappling with the reality of what it takes to replace legacy government systems.
Another grain of sand on the beach of things that we're completely unequipped to deal with, I guess.
Metformin is relatively kidney safe and not administered by IV. Thank you for clarifying that for anyone that may currently on or considering Metformin. It would be great if medical professionals were infallible communicators and had time to verify understanding, but they are human and we need more doctors and less time-pressure by profit extracting private equity.
Disclaimer: I am not a doctor.