A tragic medical mistake case in Polk County, Iowa involving barcodes was recently reported. A clinical laboratory technician has allegedly admitted the mistake, which involved wrongfully associating a healthy man with the cancerous prostate file of a different man. Surgery was performed on the healthy man, with life altering results including incontinence and impotence.

The article focuses on the pain and suffering of the injured party. There can be no doubt his life is profoundly damaged; there is no intention here to minimize that. Devastating mistakes such as this are opportunities to expose system deficiencies that should be error-proof:

• Medical document handling must adhere to well thought-out protocols
• critical data entered into a medical record must be verified by a second person
• other system checks must be in place to prevent the association of mismatched data

Not to belittle the magnitude of this occurrence, it is another instance of Murphy’s Law: “If anything could go wrong it probably will.” That is exactly what a system is supposed to prevent.

Entering critical (or even non-critical) medical information should not be done at a work station piled with multiple medical records. A clear and precise protocol must specify how records are handled. Biopsy tissue, patient medical records and pathology reports must all be associated to a single data base. Each component part must be barcoded.

I have a lot of compassion for the injured person. I also have compassion for the lab tech who reportedly admitted to the mistake. The “system” (sic) failed and the tech is also injured by this occurrence. The system failed to protect a healthy patient from unnecessary surgery. The system failed to properly identify a patient with cancer. The system failed to avert a human error. The tech is also a victim of an incomplete (at best) system. There no winners here, only victims.

Technology gets much more trust than it deserves. Electronic medical records and barcodes are tools that support systems. When there is no “system” in place, or when that system is incomplete, mistakes such as this—or worse—can happen, have happened.

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One more point I feel reluctant but obligated to raise in regards to this instance, amplifies the human responsibility. Raising this point is in no way a form of “blaming the victim”. It is intended only to shed light on how critical the  human component is to technology–all humans including the medical technicians as well as the patients. This story makes a clear case of human error in associating a healthy patient with the wrong, unhealthy diagnostic data. That healthy patient apparently did not get a second opinion. At very least, a second opinion would have raised doubt and concern about the first opinion. Technology is a tool, not a guarantee. Implicit trust is unwarranted and ill advised.

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Humans–all involved humans–are an important part of the alliance with technology. Neither replaces the other, neither is more important, and both work best when working together.

#barcode #medical records #system failure