The Therac-25 Incident (2021)

One of the commenters on the article wrote this:

> Throughout the 80s and 90s there was just a feeling in medicine that computers were dangerous <snip> This is why, when I was a resident in 2002-2006 we still were writing all of our orders and notes on paper.

I was briefly part of an experiment with electronic patient records in an ICU in the early 2000s. My job was to basically babysit the server processing the records in the ICU.

The entire staff hated the system. They hated having to switch to computers (this was many years pre-ipad and similarly sleek tablets) to check and update records. They were very much used to writing medications (what, when, which dose, etc) onto bedside charts, which were very easy to consult and very easy to update. Any kind of dataloss in those records could have fatal consequences. Any delay in getting to the information could be bad.

This was *not* just a case of doctors having unfounded "feelings" that computers were dangerous. Computers were very much more dangerous than pen and paper.

I haven't been involved in that industry since then, and I imagine things have gotten better since, but still worth keeping in mind.

It's still an issue. I've heard stories of EMR system going down forcing staff to use pen and paper. It boggles my mind that such systems don't have redundancy.

These are commercial products being deployed.

The redundancy is pen and paper. The EMR just helps teams coordinate faster, pull up records faster, etc.

When I worked at Cerner years ago (now owned by Oracle), there were rumors that the Cerner EMR still could barely handle DST* spring forward, but could not handle DST fall back (where the 01:00 hour is repeated) -- you had do preemptively switch to pen-and-paper for the hours around the switch. I assume this was because someone back in the initial database design used local time instead of UTC for some critical patient-care timestamp fields in the database, and then had a bear of a time getting reliable times out of the database during the witching hour.

* Daylight Saving Time in the USA. And yes, everyone in the USA changes non-networked clocks twice a year because of some "brilliant idea" someone shoved through Congress in 1974.

EDIT: I wonder if Cerner finally fixed it?