The Digital Doctor by Robert Wachter

Author:Robert Wachter
Language: eng
Format: epub
Publisher: McGraw-Hill Education
Published: 2015-03-11T04:00:00+00:00

In Levitt’s case, the decision to put her faith in the bar-coding system was not born of blind trust; since it had been installed a year earlier, the system had saved her, as it had all the nurses at UCSF, many times. Unlike the doctors’ and pharmacists’ prescribing alerts and the ICU cardiac monitors, with their high false positive rates, the nurses usually found their bar-code alerts to be correct and clinically meaningful. In fact, under the old paper-based process, the drug administration phase was often the scariest part of the medication ecosystem, since once the nurse believed he had the right medicine, there were no more barriers standing between him and an error—sometimes a fatal one.

Months after the error, I asked Levitt what she thought of Epic’s bar-coding system. “I thought it was very efficient and safer,” she said. “If you scan the wrong medication, it would instantly have this alert that said, ‘This is the wrong medication; there’s not an admissible order for this medication.’ So I would know, oops, I scanned the wrong one. It saved me.”

Levitt trusted not just the bar-coding system, but UCSF’s entire system of medication safety. Such trust can itself be another hole in the Swiss cheese. While a safety system might look robust from the outside—with many independent checks—many errors pick up a perverse kind of momentum as they breach successive layers of protection. That is, toward the end of a complex process, people assume that, for a puzzling order to have gotten this far, it must have been okayed by the people and systems upstream. “I know that a doctor writes the prescription,” Levitt said. “The pharmacist always checks it … then it comes to me. And so I thought, it’s supposed to be like a triple-check system where I’m the last check. I trusted the other two checks.”

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