Technology Failures

Technology in healthcare has expanded substantially over the last two decades.From electronic health records and barcode scanning to intravenous pump integration and best practice alerts, the work of healthcare providers is more automated now than ever before.But does this technology always make patient care safer?What happens when things don't go as planned?The following are examples of reported events that illustrate errors based, at least in part, on the reliance of technology.A new registered nurse (RN) went to administer insulin but realized that the medication was dispensed in vial form, which they were not familiar with, as their clinical training in nursing school had been limited to administering insulin via patient-specific pens.Consequently, they failed to recognize that they needed to use an insulin syringe instead of a 10 milliliter syringe that was used for many other vial-based medications.They relied on the dispensing instructions from Pharmacy which read "dose 28 units, dispense 1" instead of the medication administration record (MAR) instructions.They then proceeded to scan the medication vial appropriately and entered the correct amount to match the order, assuming that the contents of the vial contained the dose of units.The patient received more than 35 times the intended dose, developed hypoglycemia, and was transferred to the intensive care unit (ICU).The patient recovered and was discharged from the ICU three days later.