Understanding Human Over-reliance on Technology

An older adult was admitted to hospital with a diagnosis of new-onset seizures. Admission orders included initiation of the anticonvulsant phenytoin (handwritten using the brand name Dilantin), 300 mg orally every evening. Before the pharmacy closed, a pharmacy staff member who was new to the clinical area entered the Dilantin order into the pharmacy computer system, so that the medication could be obtained from an automated dispensing cabinet (ADC) in the patient care unit overnight. In the pharmacy’s computer system, medication selection for order entry was performed by typing the first 3 letters of the medication name (“dil” in this case) and then choosing the desired medication name from a drop-down list. The computer list contained both generic and brand names. The staff member was interrupted while performing the order entry. When this task was resumed, diltiazem 300 mg was selected instead of Dilantin 300 mg.