This past week, our daughter turned 4 months old and this meant another routine visit to the pediatrician office for her vaccinations. It started out like any other visit. The medical assistant took her weight and measurements, and reviewed the vaccines that were due this visit. She noted that our daughter would receive three shots: DTap/Hib/Polio, Hepatitis B, Pneumococcal, and an oral drink for Rotavirus.
Our daughter received a clean bill of health from the pediatrician and we were also pleasantly surprised to hear that she ranked in over 85th percentile for her weight, height, and head circumference. The last thing the pediatrician reviewed with us was her vaccinations. She briefly checked off on the 4-month overview sheet that she would receive the DTap/Hib/Polio, Pneumococcal, and Rotavirus. She crossed out Hepatitis B and said she does not need it this visit because she already received two doses (the schedule for Hep B is at 0, 1-2, and 6 months). The order was placed and the pediatrician quickly left the room while we waited for the medical assistant to return.
During this time, my wife realized that the medical assistant had mentioned that our daughter would be receiving 3 shots, not 2 like what the pediatrician had said. Sure enough, when the medical assistant returned with her tray of shots, there were 3 shots and a drink. My wife quickly stated to the medical assistant that the doctor said there were to be only 2 shots. The medical assistant then went over to the computer to double check the orders and stated that the doctor changed the orders (unbeknownst to her). Luckily, my wife works in healthcare and was able to catch the mistake before it had happened, making this incident a “near miss.”
While driving home, I could not help but think about the near mishap with our daughter. Some might say this was the fault of the medical assistant as the doctor had placed the correct order, but honestly I am not sure I would place the complete blame on her for the mistake. As I discussed this further with my wife thinking through some of the possible scenarios on how this could have happened
- Maybe the medical assistant had the vaccination schedule memorized as they work with children all day long, but perhaps she had forgotten it or did not even bother to look at the actual order?
- Maybe the medical assistant miss-read our daughters medical record and thought she was due for Hep B shot?
- Maybe the doctor actually did change or put in the order right before she had prepared up the shots but didn’t bother to verbally tell the medical assistant?
- Maybe the medical assistant was just tired that day?
In all the scenarios that we could come up with, it was clear to me that the mistake was due to the "human factor".
In my mind, why was there not an automated system and safety measures put into place that could alarm the administrator of the drug between what was ordered and what was being checked out, even to the point before the drugs were being administered? One might say having an Electronic Medical Record (EMR) system could have prevented this, especially if the drugs have bar codes that could be scanned during the preparation of the order. However, this particular clinic had an EMR system and even if the above process existed, I still believe this mistake could have easily been overlooked since someone would still have to remember to scan the drugs. What if the person giving the drugs was in a rush and just grabbed the drugs in advanced?
This incident actually reminded me of a local story that I had read several months back where a child at the UCSF Benioff Children's Hospital was accidentally given dosage that was 38 times over their normal dose. This incident occurred because a nurse had completely relied on the EMR system and had accepted the incorrect measurement conversion which then of course translated to a much higher dosage to be prescribed. Even with a modern hospital where an EMR system was used and was tightly integrated with patient drug orders and the distribution of the drugs, the system was still unable to prevent this mistake from happening.
I know we cannot solely rely on ourselves because of the "human factor" with its unpredictable nature and the primary reason we humans are not good at performing repetitive tasks or even some basic math for that matter. However, I also do not think we are ready (yet?) to place our complete trust onto computers and remove ourselves completely from the equation. What I do know is that whatever solution we come up with, we desperately need an automated system that is "naturally integrated" into the existing processes and workflows of our Healthcare system. The system needs to be an enabler to physicians, nurses, medical assistant, etc. but it cannot be a distraction or an inhibitor when providing patient healthcare.
Sadly, that is not the case today and with a diverse age group with varying digital literacy skills, I often hear from many of my friends who work in the Healthcare system that existing EMR systems are still as problematic as they are helpful. I think ultimately, whatever technology we use, it cannot be something that we have to think about using but it should be seamlessly integrated into the overall patient healthcare process with proper checks and balances.
People make mistakes every day, even with the very best technology at their disposal, it's human nature.
Ahead of every pediatrician visit, I always know which vaccines I intend my child to have, and I check the labels as well as note the lot number before each vaccine.
Sorry this happened to you!
Glad you were able to avoid a much more dire outcome.
Thanks for sharing your experience. I need to be more vigilant over this in the near future.
j capone says
an extra shot is not fun but there would have been no harm to your child if she were to have received the extra s hot once the immune system is immune you could give 50 shots and nothing would happen its just like actually getting the virus, for example we only get chicken pox once because our immune system receives it fights it off and we are now immune. I just do not think its that big of a deal for me but I understand how some people may think it is.