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November/December 2019

Editor’s Note: To Err Is (Only?) Human
By Lee DeOrio
For The Record
Vol. 31 No. 10 P. 3

Somehow, some way, the 80-year-old woman was prescribed glipizide, an antidiabetic medication. Unfortunately, the woman did not have diabetes. She wound up at the emergency department, where the mistake was discovered and the patient received treatment to reverse the drug’s actions.

Naturally, when something like this occurs, everyone wants to get at the root of the problem to prevent a repeat. Cynics might say the motive for investigating is more pointed toward assigning blame. Whatever the case may be, in this particular instance the prescription was there in plain sight in the patient’s EHR.

When discussing the error with her partners, the physician discovered that others had noticed similar instances of patients receiving medication prescribed for other patients.

According to the Cooperative of American Physicians, the medical group contacted the EHR provider, which responded with a generic message several weeks after the incident, stating, “A few clients have recently reported that documents are being moved to another chart upon signing. We investigated this issue today … and we found this may happen to any type of document that is signed from the mailbox; ie, the current document may be misfiled into the previous patient’s chart right after being signed. Please watch for any misfiled documents in patients’ charts.”

The vendor offered a workaround while it worked on a software update. Uh, perhaps it would have been wise of the vendor to be proactive and alert its customers of what was going on when it first heard about a potential glitch?

The incident was far from over. The patient sued for medical malpractice and a cross-complaint was filed against the EHR vendor, which in turn alleged that the physician was solely at fault. After all, it was she who signed off on the prescription. That, in effect, laid the responsibility on the physician’s doorstep.

Court records show that the vendor argued that the physician entered the necessary information and “clicked the requisite tabs and icons” for the software to initiate her electronic signature for the prescription. There was “no bug or anomaly in the software, and the software did not issue any prescriptions on its own accord.”

The bottom line is don’t trust the EHR—even (especially?) if that’s the sales pitch. Physicians must review every entry as if it were handwritten and assume that software bugs are essentially their responsibility.