DeMarco’s refusal to accept the hospital’s silence, a desire for accountability, and ultimately a simple request for the hospital’s administration to sit down with him and apologize for the mistakes made were enough to make the hospital change its ways.
In a high-reliability culture, a paradigm exists that simply states that it is not realistic to expect zero human error. Human error is ubiquitous; it is inevitable. As much as we dictate policy and guidelines, as much as we practice and train, humans will commit errors; it is a constant.
Among other infection control practices for hemodialysis, surveyors will be observing water and dialysate testing, medication storage, preparation and administration, and “patient placement in full view of staff during dialysis treatment,” according to a Joint Commission official.
This type of error could happen anywhere given current system vulnerabilities frequently found in hospitals, particularly when using automated dispensing cabinets. In fact, ISMP has observed many of the same system vulnerabilities in other hospitals, and they are frequently at the root of a variety of medication errors reported to the ISMP National Medication Errors Reporting Program.
Although individuals on the panel expressed slightly differing views overall, they agreed that AI in healthcare is an overhyped concept inappropriately attributed to programs that do not fit any reasonable definition of AI tools.
For nearly a decade, healthcare professionals and medical device manufacturers have been aware that medical devices, including insulin pumps and pacemakers, can be hacked. While some strides have been made in securing these types of devices, the growing interconnectivity of smart medical devices continues to outpace security.