"Dumb Docs"... Ouch.  That seems like an unwarranted
slap.  Of course all errors that occur are because the
doctor is "dumb", right?

Kevin

--- Thurman Pedigo <[EMAIL PROTECTED]> wrote:

> It's already on the WIRE:
>
http://www.wired.com/news/medtech/0,1286,67639,00.html?tw=wn_tophead_6
> Computers No Cure for Dumb Docs 02:00 AM May. 26,
> 2005 PT
> 
> What is interesting about this article is it comes
> from the back yard of
> Intermountain Healthcare (IHC) and Brent James,M.D.,
> the legendary medical
> quality guru who has probably impacted our health
> systems to save more lives
> than almost any living clinician. It was his study
> that set the standards
> for pre-operative prophylactic antibiotics in the
> 80's. Among other of his
> accomplishments is the demonstration that adverse
> drug events (ADE) jumped
> from 15/year in the 80's (detected by incidence
> reporting), to 580 in 1991
> when IT was added to the equation. Few reporting
> environments are as open in
> reporting weaknesses as this group (IHC and VA).
> 
> In this (Archives) study, only 1% of all ADEs were
> documented in the allergy
> and adverse reaction section of the record. It's
> also important to note that
> only 1% of all the errors were dispensing and 0%
> transcription. The authors
> point out the need for decision support if we are to
> further impact ADEs. 
> 
> Thanks,
> 
> thurman
> 
> 
>   
> 
> > -----Original Message-----
> > From: [EMAIL PROTECTED]
> [mailto:hardhats-
> > [EMAIL PROTECTED] On Behalf Of
> Nancy Anthracite
> > Sent: Sunday, May 29, 2005 12:07 AM
> > To: [email protected]
> > Subject: Re: [Hardhats-members] Archives of
> Internal Medicine Article
> > 
> > It was pointed out in the article, and I should
> have mentioned it, the the
> > reason the counts were high is because the system
> was able to identify
> > them.
> > 
> > It also mentioned that drug interactions were
> checked, although the
> > interaction checking was not described inthe same
> detail as you described
> > it.
> > The article said that other things, like making
> sure a checks of serum
> > potassium were ordered for the future for patients
> started on Lasix, were
> > not
> > implemented. It was not blaming the records system
> for causing the high
> > numbers, but it was indicting it for not having
> better decision support to
> > prevent the high numbers.
> > 
> > As I understand it, some of that sort of decision
> support is implemented
> > but,
> > as you can imagine, the amount of decision support
> that is available on a
> > system could vary very widely in type, amount and
> quality from system to
> > system. Readily available, targeted order sets
> were felt to be one way to
> > cut
> > down on these problems.
> > 
> > On Sunday 29 May 2005 01:26 am, Chris Richardson
> wrote:
> > > Nancy;
> > >
> > >   There is drug/drug, alergy, and drug/food
> interaction associated with
> > > orders (OR*).  At the hospitals, drug orders are
> written by physicians
> > > (bolstered by CPRS) and must be reviewed and
> signed by a pharmacist.
> > Then
> > > the point of care interface, Bar Code Medication
> Administration (BCMA)
> > > system (PSB*) also is another check to make sure
> that the proper drug is
> > > given in the proper dose at the proper time to
> the proper patient. The
> > > nurse is the final check on the delivery of the
> drug and records the
> > result
> > > of the administration (dose given/patient
> refused/etc).
> > >
> > >   Please remember that the increased counts are
> a measure of looking for
> > > these errors as well as having automated methods
> of the recording of the
> > > dispensing of the drugs.  The actual count of
> drug errors in hospitals
> > > where these automated methods are not used may
> never be known.   If drug
> > > delivery cannot be measured in a meaningful way,
> no policy change is
> > likely
> > > to have much effect.
> > >
> > > ----- Original Message -----
> > > From: "Nancy Anthracite" <[EMAIL PROTECTED]>
> > > To: <[email protected]>
> > > Sent: Saturday, May 28, 2005 9:27 PM
> > > Subject: [Hardhats-members] Archives of Internal
> Medicine Article
> > >
> > > > The May 23rd issue of the Archives of Internal
> Medicine had an article
> > >
> > > about
> > >
> > > > the high rates of adverse drug related events
> noted in a VA Hospital.
> > The
> > > > lack of decision support for selection, dosing
> and monitoring was
> > cited
> > > > as
> > >
> > > a
> > >
> > > > deficiency in the EMR that if corrected, 
> might prevent some of these
> > > > problems. The presence of drug interaction
> checking was mentioned.
> > > >
> > > > The abstract is here.
> > > > 
>
http://archinte.ama-assn.org/cgi/content/abstract/165/10/1111
> > > >
> > > > It is my understanding that there is some
> decision support already
> > > > present
> > >
> > > in
> > >
> > > > VistA but it is less than the ideal according
> to this article
> > > >
> > > > I doubt any record system out there is ideal,
> but I can see this as
> > >
> > > something
> > >
> > > > that will be cited as a reason not to adopt
> VistA .  I bring it to
> > your
> > > > attention so you will not be surprised by this
> also so that we can
> > work
> > > > toward adding more decision support to VistA
> with the help of the
> > medical
> > > > community as it grows.
> > > >
> > > > I am hoping that the release of VistA Office
> and the web site that
> > will
> > >
> > > come
> > >
> > > > with it will be a place for the  VIstA users
> to debate and contribute
> > > > specific decision support suggestions as well
> as templates, clinical
> > > > reminders, etc.  I hope that users within the
> VA will also be willing
> > to
> > > > contribute and that this will lead to
> improvements in VistA for
> > > > everyone's benefit.
> > > >
> > > >
> > > > --
> > > > Nancy Anthracite
> > > >
> > > >
> > > >
>
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