Saturday, August 26, 2000

Drug System Faulted

By John J. Lumpkin Journal Staff Writer Albuquerque VA hospital administrators have reactivated a medication-tracking computer system that continues to draw fire from the nurses' union, which claims it still doesn't work. "We feel like we've done everything we can to correct the errors we knew of," said Annie Cook, the hospital's clinical applications coordinator, on Friday. She said the only way to work out any additional bugs is to put the system into use. But union president Susan Brooks, who initially protested the system, saying it was dangerous, said the computer system still isn't getting the right medicine to the right patient at the right time. "The system is full of errors," she said during a press conference Friday. Those errors could lead to patients receiving the wrong medicine and wrong dosages, she said. The $491,000 computer system uses bar codes that a patient wears on a wristband. Nurses swipe the bar code to find out what medication a patient should receive. It first went online in April. Nurses complained it didn't always give them the right information and in some cases they averted injuries to patients only by contradicting the computer, Brooks said. But nurses weren't able to catch every error. In one case, the computer system told a nurse to give a patient insulin, but it omitted a note to put him on a special diet first. The patient received the insulin without the diet, and his blood sugar reached a dangerous level. The medical staff "pulled him out of a life-threatening situation," Brooks said. Hospital administrators acknowledged the incident and said they modified the computer system to make sure it wouldn't happen again. A hospital administrator said the computer didn't necessarily make the difference in the mistake. "In a paper system, that would have happened," said Spencer D. Ralston, the Albuquerque VA's chief operating officer. Ralston, Cook and John Erb, chief of the hospital's pharmacy, said they knew of no injuries to patients since the system went back online. Medication errors are a fact of life in a hospital, officials said  whether with a handwritten system or a computer one. "As long as we have humans involved in the drug-administration process, we're going to have errors," Erb said. In some cases, the new computer system is merely highlighting those human errors, he said. Brooks and other union officials acknowledged the system could ultimately be useful, but she charged VA managers with bringing it online too quickly to meet deadlines from their bosses at regional VA headquarters and in Washington. Asked about this, Erb said administrators would never have turned it off in the first place if they were concerned with what their bosses thought. They wouldn't have turned it back on if they still believed it unsafe, he said. But Brooks said nurses need more training with it, and it needs a backup system for nurses to use when the main system goes down. Erb said a backup system is in place. It receives downloads of patients' medication orders every two hours, so doctors and nurses can refer to it. Brooks said the system is not readily available to nurses. JOHN ERB, CHIEF OF VA HOSPITAL'S PHARMACY

http://www.abqjournal.com/news/109404news08-26-00.htm

-- Doris (reaper1@mindspring.com), August 26, 2000