Negligent nurses? Or dodgy digital?

by Harold Thimbleby, Swansea University and Paul Curzon, Queen Mary University of London

It's easy to get excited about new technology and assume it must make things better. It's rarely that easy. Medical technology is a case in point, as one group of nurses found out. It was all about one simple device and wearable ID bracelets. Nurses were taken to court, blamed for what went wrong.

The nurses taken to court worked in a stroke unit and were charged with wilfully neglecting their patients. Around 70 others were also disciplined though not sent to court.

There were problems with many nurses' record keeping. A few were selected to be charged by the police on the rather arbitrary basis that they had more odd records than the others.

The case came about because of a single complaint. As the hospital, and then police, investigated, they found more and more oddities, with lots of nurses suddenly implicated. They all seemed to have fabricated their records. Repeatedly, their paper records did not tally with the computer logs. Therefore, the nurses must have been making up the patient records.

Critical Tests

The gadget at the centre of the story was a portable glucometer. Glucometers allow the blood-sugar levels of patients to be tested. This matters. If blood-sugar problems are not caught quickly, seriously ill patients could die.

Whenever they did a test, the nurses recorded it in the patient's paper record. The glucometer system also had a better, supposedly infallible, way to do this. The nurse scanned their ID badge using the glucometer, telling it who they were. They then scanned the patient's barcode bracelet, and took the patient's blood-sugar reading. They finally wrote down what the glucometer said in the paper records, and the glucometer automatically added the reading to that patient's electronic record.

Over and over again, the nurses were claiming in the notes of patients that they had taken readings, when the computer logs showed no reading had been taken. As machines don't lie, the nurses must all be liars. They had just pretended to take these vital tests. It was a clear case of lazy nurses colluding to have an easy life!

What really happened?

In court, witnesses gave evidence. A new story unfolded. The glucometers were not as simple as they seemed. No-one involved actually understood them, how the system really worked, or what had actually happened.

In reality the nurses were looking after their patients ... despite the devices.

The real story starts with those barcode bracelets that the patients wore. Sometimes the reader couldn't read the barcode. You've probably seen this happen in supermarkets. Every so often the reader can't tell what is being scanned. The nurses needed to sort it out as they had lots of ill patients to look after. Luckily, there was a quick and easy solution. They could just scan their own ID twice. The system accepted this 'double tapping'. The first scan was their correct staff ID. The second scan was of their staff card ID instead of the patient ID. That made the glucometer happy so they could use it, but of course they weren't using a valid patient ID.

As they wrote the test result in the patient's paper record no harm was done. When checked, over 200 nurses sometimes used double tapping to take readings. It was a well-known (at least by nurses), and commonly used, work-around for a problem with the barcode system.

The system was also much more complicated than that anyway. It involved a complex computing network, and a lot of complex software, not just a glucometer. Records often didn't make it to the computer database for a variety of reasons. The network went down, manually entered details contained mistakes, the database sometimes crashed, and the way the glucometers had been programmed meant they had no way to check that the data they sent to the database actually got there. Results didn't go straight to the patient record anyway. It happened when the glucometer was docked, but they were constantly in use so might not be docked for days. Indeed, a fifth of the entries in the database had an error flag indicating something had gone wrong. In reality, you just couldn't rely on the electronic record. It was the nurses' old fashioned paper records that really were the ones you could trust.

The police had got it the wrong way round! They thought the computers were reliable and the nurses untrustworthy, but the nurses were doing a good job and the computers were somehow failing to record the patient information. Worse, they were failing to record that they were failing to record things correctly! ... So nobody realised.

Disappearing readings

What happened to all the readings with invalid patient IDs? There was no place to file them so the system silently dropped them into a separate electronic bin of unknowns. They could then be manually assigned, but no way had been set up to do that.

During the trial the defence luckily noticed an odd discrepancy in the computer logs. It was really spiky in an unexplained way. On some days hardly any readings seemed to be taken, for example. One odd trough corresponded to a day the manufacturer said they had visited the hospital. They were asked to explain what they had done...

The hospital had asked them to get the data ready to give to the police. The manufacturer's engineer who visited therefore 'tidied up' the database, deleting all the incomplete records...including all the ones the nurses had supposedly fabricated! The police had no idea this had been done.

Suddenly, no evidence

When this was revealed in court, the judge ruled that all the prosecution's evidence was unusable. The prosecution said, therefore, they had no evidence at all to present. In this situation, the trial 'collapses': the nurses were completely innocent, and the trial immediately stopped.

The trial had already blighted the careers of lots of good nurses though. In fact, some of the other nurses pleaded guilty as they had no memory of what had actually happened but had been confronted with the 'fact' that they must have been negligent as "the computers could not lie". Some were jailed. In the UK, you can be given a much shorter jail sentence, or maybe none at all, if you plead guilty. It can make sense to plead guilty even if you know you aren't -- you only need to think the court will find you guilty. Which isn't the same thing.

Silver bullets?

Governments see digitalisation as a silver bullet to save money and improve care. It can do that if you get it right. But digital is much harder to get right than most people realise. In the story here, not getting the digital right -- and not understanding it -- caused serious problems for lots of nurses.

It takes skill and deep understanding to design digital things to work in a way that really makes things better. It's hard for hospitals to understand the complexities in what they are buying. Ultimately, it's nurses and doctors who make it work. They have to.

They shouldn't be automatically blamed when things go wrong because digital technology is hard to design well.