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Death by 1000 Clicks Redux
Health Care Blog April 8, 2019
Back in the ‘stone ages’ when I (an MIT grad) was an intern, I was called at 4 AM to see someone else’s gravely ill patient because her IV had infiltrated. I started a new one and drew some blood work to check on her status. When the results came back (on paper) I (manually) calculated her anion gap. This is simple arithmetic but I had been up all night and didn’t do it right.
She died.
On morning rounds the attending assured me that there was nothing I could have done anyway but, of course, in other circumstances it could have made a difference and an EHR could have easily done this calculation and brought the problematic result...
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