Cancer Patient is Killed by Drug Overdose Caused by Alleged Software Error

Joseph O'Neill

Written by
— Updated on January 10, 2022

Hospital MedicineThis case involves a middle-aged female who was diagnosed with cervical cancer. After undergoing a tumor cryoablation treatment for her cervical cancer for some time, she reported the onset of neurological symptoms. At this point, doctors discovered that her cancer had metastasized to several other organs. The patient was kept in the hospital for several days, after which time she was released to the care of a skilled nursing facility. While at hospital, the patient was receiving medication to treat high blood pressure. However, when the patient was discharged from the hospital, the discharge paperwork incorrectly indicated that the patient should receive more than double the dosage she had been receiving in the hospital. Once admitted into the skilled nursing facility, the jump in dosage caused severe beta blocker toxicity in the patient almost immediately. The patient was taken by ambulance back to the hospital, where she died several days later. Doctors claimed that the software system should have prevented this fatal miscommunication of dosage.

Question(s) For Expert Witness

  • 1. Can you speak to the training physicians are required to receive prior to using the software system in question?
  • 2. Can you speak to complications that can occur with the program, specifically implementing prescription dosages?
  • 3. Does this system have preventative programs in place to help prevent human input error?

Expert Witness Response E-001692

I work in a hospital setting and I am on-staff at multiple hospitals.  There are required classes all doctors need to take and certification is offered by the hospital before doctors “go live” with the system discussed above. Also, there are “superusers” whose job is to guide and work in groups to help doctors get quality work done with the system in question. I have been trained to use this system, and was the very first doctor to “go live” the first day as I admitted the very first patient to the hospital on the system. It is not easy to blame the software for human input error. The system has multiple checks to prevent the wrong dose from being accepted. Ultimately, the ordering physician needs to take responsibility for re-reading the final discharge reconciliations or for creating new discharge reconciliation, otherwise it will be incorrect for many patients. This software has preventative programs in place and has safety as its first mission. Unfortunately, if the physicians wish to circumvent the safe method built into the system, they can do that. Discharge reconciliation is required especially for the inter-facility transfer. In case of any questions, the receiving facility is to call the sending facility to verify the nature of orders. The discharge process standard of care is no different using this particular system versus any other electronic record.

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