Jailed man narrowly escapes fatal error in electronic health record


Heart patient nearly received lethal dose of medication.

In one of a series of alleged errors by a county jail’s new electronic health record system, the EHR recommended what could have been a fatal dose of medication for a heart patient, the jail’s nurses said this week.

A nurse in the Contra Costa jail who is familiar with the patient noticed the discrepancy and administered the proper dosage, the Contra Costa Times reported Tuesday. The new $45 million EHR, which integrates jail medical records with other county health records, drew 142 complaints from nurses during its first month in operation, a nursing union representative told county commissioners.

"I have never in all the time working with the California Nursing Association seen that many (complaints) be filled out," the union representative, Jerry Fillingim, told the newspaper. "Each day these nurses are fearful that they will kill somebody . . . I think the county tried to rush it, making it comprehensive for everything."

Lee Ann Fagan, the registered nurse who says she caught the drug discrepancy, called the EHR “dangerous” in an interview with the newspaper. "It's hard to work in an environment that's so frustrating. What nurses want is for the [electronic health record system] to go away until it's fixed," she said.

Fagan said super-users responsible for training other staff on the EHR had warned county health leaders of problems with the system. Four hours of training before the electronic system went live were “next to useless because the program wasn’t in place well enough to practice,” she told the newspaper.

She and Fillingim said the problems have been most severe in the jail.

In a commentary that appeared in the newsletter EHR Intelligence, writer Kyle Murphy says the Contra Costa jail problems raise a red flag and potentially damages the vendor’s ability to regain user trust. But he also questioned whether human error played a role, noting that the EHR had only been in use for a month and that users had received only two, two-hour training sessions.

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