Jerry Fahrni

Month: November 2011

  • Fatal overdose of KCL caused by poor handwriting, lack of diligence

    imageISMP Medication Safety Alert: “A nursing home resident died from cardiac arrest after receiving a 10-fold overdose of oral potassium chloride because an order for 8 mEq was misinterpreted by several facility staff members as 80 mEq.” – A poorly handwritten order was a contributing factor to the error. What’s really scary about this error is that an 80 mEq dose of KCL is big, but not unheard of. I’ve entered orders for 80 mEq of oral potassium, however never for a nursing home patient. According to the ISMP Alert “[t]he pharmacist dispensing this medication to the nursing home recognized this was an "unusually high dose" but confirmed it was "correct" by calling the nursing home and speaking with one of the nurses.”

    Some simple things that could have prevented this error include some type of CPOE system, a healthy dose of clinical decision support software and pharmacy access to laboratory data. Any one of these could have made the difference.

    One other thing worth mentioning. Orders for oral KCL greater that 40 mEq per dose are typically accompanied by instructions for a set number of doses, i.e. 80 mEq po daily x2 doses for hypokalemia. It’s a simple thing, but could be the difference between electrolyte correction and death. In this particular instance the patient received the dose for 8 days before succumbing to hyperkalemia. 

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    image taken from ISMP Medication Safety Alert, Nov. 3, 2011, Vol 16, Issue 22

  • Portable storage media, the scourge of patient privacy

    LA Times: “Altogether, 16,288 patients’ information was taken from the home of a physician whose house was burglarized on Sept. 6, according to the UCLA Health System.

    The data were on the physician’s external hard drive, officials said. Though the hard drive was encrypted, a piece of paper with the password was nearby and is also missing. The physician notified UCLA the next day and officials began identifying patients affected.”

    I am continuously amazed at the number of security breaches involving patient healthcare information caused by careless use of portable storage media like external hard drives, flash drives, and even laptop hard drives. Patient information should never be stored or transported this way. I believe that utilizing cloud computing with simple browser access is a much better solution. 

    What makes this particular incident so bad is the cause; reckless behavior by a physician. This wasn’t UCLA’s fault, per se. Sure, the medical center must accept a share of the responsibility, the lion’s share of the blame falls in the lap of the physician. Not only did the physician have sensitive patient information on an external hard drive, but was dumb enough to have the password to access the drive on a piece of paper next to it. Kind of defeats the purpose of encryption and passwords, doesn’t it.

    For an eye-opening look at the magnitude of data loss and security breaches drop by DataLossDB.org sometime. It’s scary stuff.