Are information technologies such as PDAs safe for use in clinical practice? While the application of handheld computers may improve the quality of patient management, the combination of potential human errors and software pitfalls may lead to serious problems in patient care at clinical settings. In this case report, the error of a resident along with software inadequacies for drug dosage calculations led to a serious error in the ICU. The resident used a PDA for calculating noradrenaline dosage for an infant, and an error while using the PocketExcel sheet led to a sevenfold higher dosage. This case report suggests that standard protocols need to be designed for testing PDA clinical software before they are used in clinical settings.
Information technology cannot guarantee patient safety
de Wildt SN, Verzijden R, van den Anker JN, de Hoog M. BMJ. 2007 Apr 21;334(7598):851-2.
Reviewed by Iman Tavassoly
This article explores the possible inadequacy of PDAs for patient safety.
Case report
HIGHLIGHTS: In the application of information technology tools such as PDAs in clinical practice, the combination of software inadequacy and human errors may lead to failures in patient management.
IMPLICATIONS: To avoid potential clinical errors, clinical software should be evaluated based on standard protocols before they are adopted for clinical practice.
GENERALIZABILITY: This case may occur in other clinical settings where PDA software is used before they are tested against standard protocols.
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