Have you ever witnessed the organized chaos in an Emergency Department on a Friday night? The dancing of nurses, doctors and ancillary staff weaving and gliding around to help the injured and comfort the ill? Have you ever witnessed that come to a jarring halt, accompanied by an influx of staff, running towards the dedicated room when a trauma code is called?

Have you ever known someone who has been in the unfortunate position of being that trauma patient? Perhaps a neighbor, a friend, a parent, or a child? Has it ever been you?

The medical field is comprised of a group of people with the best of intentions. Intentions guided by empirical evidence. Intentions guided by hope. We busy ourselves with continuing education, training to (and above) standards, absorbing new procedures- all in the effort to be… better. Information system software has been a close ally in our efforts, processing unprecedented amounts of information and playing a vital role in patient safety. Of course, it can also be our enemy.

Ally or enemy?

I entered a stoic blood bank; two other blood bankers flurried around, murmuring to themselves as they prepared coolers for the Massive Transfusion pack for the patient in the Emergency Department for a Motor Vehicle Accident. “Can you thaw some more plasma?” the Lead Blood Bank Tech asks me before she returns her attention to dispensing the first cooler full of product. “What type?” I ask the other blood banker as I walk towards the freezer. “O Neg” she responded, scanning in a unit of type O negative red blood cells. I quickly pull-out four type O plasma and put it the water bath. 20 minutes later I am standing in front of a computer ready to assign the thawed units to the patient and see: ABO mismatch.

What happened? The Lead Blood Bank Tech had instructed the other blood banker to set up O negative blood. With all the commotion, she did not hear it was because we did not have a specimen to test and were giving universal compatible blood products (O negative red blood cell products and type AB plasma products). The system had, thankfully, done its job and prevented this potential sentinel event.

Ally or enemy?

Sometime in the hour of 3am my phone rings. As the new blood bank supervisor, I am expected to take emergency calls during all hours. Sorry to wake you Beth, but I made a pediatric platelet aliquot, and the computer is saying something about ‘invalid application status.’ I’ve tried everything I can think of. The doctor is really upset and wants me to just give his patient the needed unit.

What was causing grief and frustration was fixed in the system in about one minute when I escalated this issue to the Laboratory Information System department. And it only took that long because I had to explain the situation. Well, it took that one minute to fix the mistake but then it took time to complete the Blood Bank Occurrence paperwork due to a forced manual dispense because of the mistake. And then time to ensure the patient chart accurately reflected the correct information since the transfusion could not be recorded in the system concurrently. And then time to develop an action plan to mitigate future occurrences. And then time to meet with the safety committee and explain what happened and present our action plan.

Working in the laboratory science field for over 20 years, I have seen multiple occurrences of near misses prevented by software. Our nurses, doctors, and ancillary staff rely on the technology to help us in times when we cannot help ourselves. Software can increase our ability to treat patients more effectively and is an ally to increase patient safety. However, if not setup correctly it can become an enemy, and patient care is detrimentally impacted. Our hard-working medical professionals can become frustrated when the care they want to provide is obstructed by mistakes in the software. They perform workarounds causing decreased morale and increased costs.

Testing and validating our hospital software shouldn’t be done grudgingly for auditors and inspectors, it should be done enthusiastically for our nurses, doctors, and ancillary staff. It should be done robustly for our neighbors, friends, parents, and children. With the colossal impact our software has, we should be asking: How can it be… better?