Sifting through safety reports at your facility in search of
significant issues is daunting. CHPSO shares the challenge: we
have about 870,000 reports and more arrive daily.
This challenge is also an opportunity, as we aggregate
information from hundreds of providers, and can observe patterns
and commonalities in risks and causes that may not be obvious at
a single site.
This brings us to the four-letter word of danger. We have found a
large number of events in which “auto” signals a significant
cause. Sometimes the word is part of a larger word, such as
autocorrect, auto-cancel, auto-fax or
Whether alone, or as part of a compound word, this is a signal
that the automatic actions of the system may have surprised
someone, acted in an unexpected way, or been overly relied upon.
In short, events bearing this four-letter word are a window into
the perils of automation. In many of these cases, if a human were
actively involved, the error could have been caught.
An auto order associated with starting epidural analgesia
discontinued the narcotics given to a chronic pain patient. No
one questioned that automatic order.
Mis-transcription from the EHR to the pharmacy computer resulted
in autofill of a syringe to 20X the ordered dose, which was then
placed in the automated dispensing cabinet. The nurse pulled the
dose out of the cabinet and administered it to the patient.
When dispensing a 4 mg vial, “3” instead of “3 mg” was entered in
the system. Since units were not specified, the system
automatically interpreted the 3 to be “3 vials”, dispensing four
times the intended dose.
Antibiotic was given for extended period, as auto-stop policy was
approved but to everyone’s surprise not successfully turned on in
A substitute drug was dispensed by automatic therapeutic
substitution, but the original drug not discontinued. Both were
The hospital had autostop on perioperative antibiotics. The
pre-op orders had to be altered post-op, and the EHR failed to
put the post-op order on autostop. It turned out that the
autostop rule as implemented only applied to antibiotics ordered
Changes in a patient’s “admit” status caused the system to
auto-verify unverified orders.
Blood products ordered late in the month but given the next month
were supposed to be automatically carried over to the new month,
but the system dropped some orders.
Lab technician manually corrected blood count without realizing
that the instrument had automatically corrected the blood count,
resulting in overcorrection.
About 7 am, an hour after the 6 am medications were given, the
drug order was changed to “daily.” The system automatically added
a dose at 9 am that day and cleared the MAR of the prior
medication as that had been “discontinued,” resulting in a
Physician accidentally ordered a duplicate CBC. The lab tech was
notified and deleted a CBC order. Unbeknownst to her, the system
had already detected and deleted one of the duplicate CBC orders,
so no CBC was run.
A procedure was ordered, but then automatically canceled by the
EHR as the procedure did not exist in the system (the hospital
does provide the procedure).
Suggested search strategy:
Whole text search of the narrative portions of the reports,
WHERE Word Like “auto*” And Word Not In
And Word Not Like “autop*” And Word Not Like “autotransf*” And
Word Not Like “autoclav*” And Word Not Like “autoim*”. CHPSO has
over 1200 cases meeting this criterion.