In our April 2, 2007 Tip of the Week we showed an example about how a technological advance (a dual-power source portable ventilator) gave rise to an unintended consequence. It is not at all uncommon for technological advances to create some new unintended consequences.
In the early days of telemetry, hospitals realized they could now utilize remote telemetry to free up valuable ICU beds. A hospital purchased such a remote telemetry system in which the transmitter could be placed on a patient on one floor of a hospital and the receiver/monitor was in the CCU as part of a bank of telemetry screens that were continuously viewed by a nurse assigned to that duty. One day, right around nursing change of shift, two patients were admitted to the remote floor and telemetry was ordered on both. The nurse took two transmitters with him and hooked the patients up, then called the CCU monitoring nurse to tell her about the two patients just hooked up. About an hour later the CCU monitoring nurse called the remote floor because one of the patients was in ventricular fibrillation. A code was called and the floor staff and code team ran to the patient’s room, only to find him sitting in bed, watching TV and eating a meal. Only after several minutes of fiddling with his EKG leads and talking to the nurse in the CCU did anyone realize that the patient several rooms down the hall was really the one in ventricular fibrillation. The transmitters obviously had been transposed! This is a variation of the “two in a box” phenomenon we talked about in the April 23, 2007 Tip of the Week. And, of course, the system was poorly designed in that it allowed the first nurse to take out two remote telemetry transmitters at the same time. However, we are presenting it here as an example of how a technological solution expected to enhance patient safety actually created a new unintended problem.
Another example was when a hospital purchased a new alarm system that would send an alarm when the patient got out of bed. It turned out that on some units there were not enough electrical outlets for both the new bed alarms and the nurse call buttons. So a decision was made in some cases to swap out these two devices. You can guess what happened: nursing staff responded to the “out-of-bed” alarm only to find the patient lying on the floor with an injury because he tried to get out of bed after no one responded when he pushed the nurse call button!
And there are lots of examples of unintended consequences associated with CPOE (computerized physician order entry). The classic example is correction of the illegible handwriting problem but introduction of the “cursor error” or “stylus error” in which the physician inadvertently chooses a medication above or below the one he/she actually intended to choose on the computer or PDA screen. The last issue of ISMP’s newsletter had an example of a nonventilated patient inadvertently being given a paralytic agent, in part because the ordering physician was entering orders from a remote site and accidentally ordered this for the wrong patient.
We present these cases not to discourage use of technology, which is one of our most potent weapons in the patient safety arsenal, but rather to remind all that any solution (whether technological or instituting a new approach, etc.) may give rise to unintended consequences. Sometimes they can be anticipated, other times they cannot. Either way, careful vigilance for unintended consequences is necessary.
Update: See also May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”