Home » Time Capsule » Currently Reading:

Time Capsule: Don’t Look Now, Your Loop is Open

October 14, 2011 Time Capsule No Comments

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in September 2006.

Don’t Look Now, Your Loop is Open
By Mr. HIStalk

mrhmedium

Three babies dead in Indiana, overdosed with the wrong heparin product in a hospital not using bedside barcode verification of meds. Technology failed them, plan and simple.

Ten years ago, nursing and pharmacy systems didn’t talk to each other (pharmacists and nurses didn’t either, but that’s another story.) Finally, everyone agreed that was pretty stupid, so vendors did a little bit of integration to make their systems look like they did. The electronic Medication Administration Record (MAR) was born, although most hospitals stuck with once-a-day printed versions for a several reasons, most of them illogical.

Along came CPOE, usually awkwardly bolted up to those same nursing and pharmacy systems. It was (and is) expensive, rarely used, and inefficiently designed for physicians, but it caught the eye of well-intentioned hospital executives who were blissfully unaware that all those CPOE-preventable errors weren’t the ones harming patients anyway. I like to think of it as the Job Security Act for Chief Medical Informatics Officers.

Don’t buy the ubiquitous vendor buzzword “closed loop,” which implies we’ve got meds under control. We don’t. The dent in harmful medication errors has been slight. Why? Because nurses still walk a tightrope without a net, armed only with limited drug knowledge, too much work, paper records updated with pens, and a wide-open candy machine of increasingly dangerous drugs … uhhh, I mean decentralized medication distribution cabinets.

We bought the technology least likely to be used, that addresses errors least likely to be harmful, that doesn’t help the user who needs it most, and deployed it in patient care areas where serious errors are least likely to occur.

But let’s look on the positive side. Technology is the only hope of improving the situation, so there’s opportunity galore.

If you’re a vendor with an integrated bedside verification system, get those sales guys on the road because I guarantee you’ll sell a bunch of them in the next year if yours is any good. Guarantee, I said. The Indiana errors are the pin that will pop the CPOE balloon, making even the big-picture types comprehend that they’ve been chasing the wrong solution. Board members will find the money, given the extreme embarrassment and financial exposure likely to follow a high-profile screw-up.

If you sell add-on tools for electronic MARs or have the expertise to consult in that or any other patient safety area, polish up your shingle. Plenty of organizations need your help. They haven’t fixed their own problems, so a well-dressed stranger who flies into town and has PowerPoints seems like the next thing to try.

If your company is one of the few that sells medication distribution cabinets, get some real informatics people designing improvements instead of those engineers who are more concerned with servo motors and drawer design instead of intelligent software. You could definitely do better and the market will reward you for it.

And if you’re Cerner, congratulations! You bought Bridge Medical and their bedside verification technology just at the right time and announced plans for your own line of medication distribution cabinets. You’ve got a widely installed customer base that wanted closed loop meds. If you don’t mess it up, you could build a huge business on the other half of the loop, the one that isn’t closed. I guarantee that, too.

But for goodness sake, let’s all agree not to dawdle. Too many parents will already know the sorrow of celebrating their baby’s first birthday in a cemetery.

View/Print Text Only View/Print Text Only


HIStalk Featured Sponsors

     







Subscribe to Updates

Search


Loading

Text Ads


Report News and Rumors

No title

Anonymous online form
E-mail
Rumor line: 801.HIT.NEWS

Tweets

Archives

Founding Sponsors


 

Platinum Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gold Sponsors


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reader Comments

  • Fourth Hansen Brrother: In the history of paper based charting, there were apparently plenty of instances of gang bangers entering hospitals and...
  • PM_from_haities: Pretty sure in the history of paper based charting a terrorist never came in took over a hospital and locked the filing ...
  • iPharmD: Justin Box needs to apply for immediate entry to The American College of Informatimusicology http://www.acmimimi.org/...
  • Leroy: I get that CHIME has to make money, but the question is how much is enough. I think the Associate Membership is a good i...
  • PC: More like 30,000 athena docs checking their contracts for the termination for convenience clause......

Sponsor Quick Links