Practice Lesson of the week

Information technology cannot guarantee patient safety

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39104.625903.80 (Published 19 April 2007) Cite this as: BMJ 2007;334:851
  1. Saskia N de Wildt, paediatrician1,
  2. Ron Verzijden, information technology management consultant2,
  3. John N van den Anker, neonatologist and clinical pharmacologist3,
  4. Matthijs de Hoog, paediatric intensivist1
  1. 1Department of Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands, 3015 GJ
  2. 2Ron Verzijden Management Consultants, Toronto, Canada M5J 2Y5
  3. 3Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington DC, 20010, USA
  1. Correspondence to: S N de Wildt, Hospital for Sick Children, Division of Clinical Pharmacology and Toxicology, Toronto, ON, Canada M5G 1X8 s.dewildt{at}erasmusmc.nl
  • Accepted 8 January 2007

Human error and software inadequacy can combine to make drug doses calculated on hand held computers unreliable

Information technology tools, such as those used to calculate drug doses and infusion rates, can help reduce adverse events and prevent errors.1 Drug dosages for children are usually calculated on the basis of weight. Calculations are especially prone to error and delay in crisis situations such as resuscitation. In such settings, computer based tools may improve clinical care, although human error can still occur, as illustrated by this case report.

Case report

A 3 month old infant who arrived at the emergency department of a small regional hospital had clinical signs of meningococcal sepsis with petechiae, purpura, and shock. The infant was subsequently transferred to our paediatric intensive care unit. During transfer the patient was given infusions of dobutamine and noradrenaline by the transferring intensivist. The concentrations of 12 drugs that might be needed for infusion during transport had previously been calculated in the intensive care unit by the resident. This had been done by entering the patient's weight into a preprogrammed PocketExcel sheet for a personal digital assistant (handheld computer).

When the patient arrived at the unit all running drugs were ordered using our electronic patient data management system (a bedside computer application). This system uses the patient's weight and the desired infusion rate …

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