MED-ERR-0401 medical data_error ai_generated true

AI orders a 'CMP + contrast extra blood tube' for a patient with eGFR <30 mL/min/1.73m² scheduled for CT with IV iodinated contrast, missing nephrology consult

ID: medical/contrast-extra-blood-tube-order

Also available as: JSON · Markdown · 中文
90%Fix Rate
85%Confidence
1Evidence
2024-03-15First Seen

Version Compatibility

VersionStatusIntroducedDeprecatedNotes
Epic 2023 active — — —
Cerner Millennium 2022.2 active — — —
Allscripts 17.0 active — — —

Root Cause

AI misinterpreted 'contrast extra blood tube' as a routine lab order for contrast-enhanced CT preparation, when in fact it should trigger a nephrology consult for contrast-induced nephropathy risk assessment in severe renal impairment.

generic

中文

AI将'对比剂额外采血管'误解为增强CT准备的常规实验室检查，实际上在严重肾功能不全患者中应触发肾内科会诊以评估对比剂肾病风险。

Official Documentation

https://www.acr.org/Clinical-Resources/Contrast-Manual

Workarounds

  1. 92% success Before any contrast study, check the patient's most recent eGFR (within 7 days). If eGFR <30 mL/min/1.73m², place a nephrology consult order and hold contrast pending consult recommendation. Use the hospital's contrast safety checklist (e.g., 'ContrastCheck' in Epic) to trigger automatic consult. 
    Before any contrast study, check the patient's most recent eGFR (within 7 days). If eGFR <30 mL/min/1.73m², place a nephrology consult order and hold contrast pending consult recommendation. Use the hospital's contrast safety checklist (e.g., 'ContrastCheck' in Epic) to trigger automatic consult.
  2. 88% success Implement a CDS (Clinical Decision Support) rule in the EHR: when 'contrast extra blood tube' is ordered for a patient with eGFR <30, auto-populate a nephrology consult order and display a warning: 'Contrast-induced nephropathy risk — consult nephrology before proceeding.' 
    Implement a CDS (Clinical Decision Support) rule in the EHR: when 'contrast extra blood tube' is ordered for a patient with eGFR <30, auto-populate a nephrology consult order and display a warning: 'Contrast-induced nephropathy risk — consult nephrology before proceeding.'
  3. 78% success For stat cases (e.g., suspected pulmonary embolism), administer IV fluids (0.9% NaCl at 1 mL/kg/h for 12h pre and post) and document nephrology notification as a verbal order, then follow up within 24h. 
    For stat cases (e.g., suspected pulmonary embolism), administer IV fluids (0.9% NaCl at 1 mL/kg/h for 12h pre and post) and document nephrology notification as a verbal order, then follow up within 24h.

中文步骤

  1. Before any contrast study, check the patient's most recent eGFR (within 7 days). If eGFR <30 mL/min/1.73m², place a nephrology consult order and hold contrast pending consult recommendation. Use the hospital's contrast safety checklist (e.g., 'ContrastCheck' in Epic) to trigger automatic consult.
  2. Implement a CDS (Clinical Decision Support) rule in the EHR: when 'contrast extra blood tube' is ordered for a patient with eGFR <30, auto-populate a nephrology consult order and display a warning: 'Contrast-induced nephropathy risk — consult nephrology before proceeding.'
  3. For stat cases (e.g., suspected pulmonary embolism), administer IV fluids (0.9% NaCl at 1 mL/kg/h for 12h pre and post) and document nephrology notification as a verbal order, then follow up within 24h.

Dead Ends

Common approaches that don't work:

  1. 85% fail

    Assuming the 'extra tube' order is just a normal lab request and proceeding with contrast administration without renal function review.

  2. 60% fail

    Ordering a stat nephrology consult via pager without first verifying the patient's recent eGFR trend, causing delayed imaging.

  3. 75% fail

    Flagging the order as a 'lab error' and canceling it, then reordering the same without nephrology input.