April 7, 2010

Medical Systems That First Do No Harm

Medical errors are common. Drug-delivery devices that flag nonsensical number entry could prevent a large fraction of hospital-based errors and perhaps deaths. Karen Hopkin reports

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Everyone makes mistakes, especially when it comes to entering numbers into a calculator or spreadsheet. It’s not such a big deal if you’re tracking how much you spend on pizza. But if you’re administering drugs in a hospital, such a slip can be deadly. Now a report in the Journal of the Royal Society Interface [see Harold Thimbleby and Paul Cairns, http://bit.ly/cqcD83] shows how devices can be programmed to catch at least some mistakes on the spot.

Dosing a patient with 10 times too much medication is disturbingly common. One study suggests this error occurs in 1 percent of all hospital admissions. And though the person punching in the numbers is at fault, most drug-delivery devices don’t help.

In one machine, for example, mistakenly entering a number with two decimal points—like 1.2.3—might be read by the machine as 1.23, or as a 123. To prevent such wild guessing, scientists tested a system that immediately flags any input that’s not a real number. According to their analysis, that safeguard alone could cut factor-of-10 errors in half.

Charles Darwin once noted that “to kill an error is as good a service as…establishing a new truth or fact.” Even more so when killing the error keeps you from killing a patient.

—Karen Hopkin

[The above text is an exact transcript of this podcast.]

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