"However, the nurse either misinterpreted the note or did not read it and the patient received more (potassium chloride) than the diagnosing physician intended. A second physician, not having been informed that the patient was already prescribed (potassium chloride) used the CPOE system to prescribe even more potassium chloride to the patient."
The resulting patient's overdose was ultimately blamed in part on the interface's poor design and its failure to display important lab reports and medication history.
The report mentions another adverse consequence of health IT, the case of a physician who made a "copy paste" error, the result of which gave a woman patient the diagnosis of "scrotal pain, decreased urinary stream, and dysuria."
"I used to be a doctor," the physician told the IOM. "But now I am a typist."
The 18-person committee's report makes 10 recommendations, including raising the possibility that the U.S. Food and Drug Administration might at some point exercise its authority to regulate these systems as medical devices. The committee also calls on Congress to establish an independent federal entity to investigate any patient death, injury or potential unsafe conditions associated with health IT.
The situation could be exacerbated because these days, health professionals rush to get their share of billions in meaningful use incentive payments "to adopt the very products that may be causing harm. These stories are frightening, but they shed light on a very important problem and a realization that, as a nation, we must do better to keep patients safe," the report says.