Sunday, October 05, 2014

There Is A Real Lesson Here Regarding Health IT Safety, Use And The Unanticipated Event.

The first US case of the Ebola Virus has caused a very interesting and educative event regarding a highly respected Hospital EHR System from Epic.
There is reporting here:

Scarier Than Ebola: Human Error

October 03, 2014
Texas Health Presbyterian Hospital in Dallas on Sept. 30
The Dallas hospital treating the first Ebola case diagnosed in the U.S. sent the patient, Thomas Duncan, home the first time he showed up because the doctors who saw him never learned that he’d just come from West Africa. The hospital has blamed a flaw in its electronic health records for keeping information collected by a nurse, including Duncan’s travel history, from being presented to the treating physician, who mistook Duncan’s symptoms for a low-level infection, on Sept. 25.
The apparent mistake meant Duncan was not admitted and isolated until Sept. 28. That increased the risk of infection for those he came in contact with while he was sick, including his family, who are now quarantined in their Dallas apartment. It also widened the circle of contacts that public health officials must trace and monitor for symptoms.
America’s risk of an Ebola epidemic remains vanishingly small. The country has the public health resources and hospital capacity to stop the spread of the infection, which is only transmitted through direct contact with bodily fluids after a patient exhibits symptoms. The misstep at Texas Health Presbyterian Hospital Dallas, though, indicates something patients should be spooked about: the very real chance that errors, oversights, or deviations from established procedures could kill them.
Lots more here:
Here is the release from the Hospital:

Ebola Update, Oct. 2, 8:35 p.m. CDT 10/02/2014

Texas Health Presbyterian Hospital Dallas

Report on Events Related to Ebola Diagnosis
Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.
On September 29, the first case of Ebola Virus Disease in the United States was diagnosed at Texas Health Presbyterian Hospital Dallas. The doctors, nurses and other caregivers at Texas Health Dallas continue to provide compassionate intensive care to our patient, Mr. Thomas Duncan. Mr. Duncan remains in serious condition.
Texas Health Dallas is on alert for communicable diseases as we treat patients who visit our hospital, and particularly our emergency department. As a hospital, we have expertise in treating communicable diseases and have evidence-based screening processes in place. Texas Health Dallas strengthened and deployed updated communicable disease protocols on September 1, 2014.
In response to questions raised about Mr. Duncan’s first visit to the hospital emergency department on the night of September 25th, we have thoroughly reviewed the chain of events. In the interest of transparency, and because we want other U.S. hospitals and providers to learn from our experience, we are, with Mr. Duncan’s permission, releasing this information.
In diagnosing potential causes of infectious diseases like Ebola, Texas Health Dallas care teams are trained to look for multiple indicators, including the following:
1. Does the patient present with symptoms that indicate potential communicable disease?
  • Mr. Duncan presented with a temperature of 100.1F, abdominal pain for two days, a sharp headache, and decreased urination. These symptoms could be associated with many communicable diseases, as well as many other types of illness. When he was asked whether he had nausea, vomiting, or diarrhea, he said no. Additionally, Mr. Duncan’s symptoms were not severe at the time he first visited the hospital emergency department.
2. Has the patient been around anyone who has been ill?
  • When Mr. Duncan was asked if he had been around anyone who had been ill, he said that he had not.
3. Has the patient traveled outside the United States in the last four weeks?
  • Mr. Duncan was asked if he had traveled outside the United States in the last four weeks, and he said that he had been in Africa. The nurse entered that information in the nursing workflow of the electronic health record.
When patients visit the emergency department, they are first assessed by a triage nurse. Then an intake nurse conducts a more thorough screening process that includes:
  • vital signs;
  • general clinical assessment;
  • a neurological assessment; and
  • questions about major risk factors:
    • domestic violence;
    • tetanus status;
    • tuberculosis risk;
    • travel history outside the United States in the previous 4 weeks;
    • suicide risk assessment; and
    • falls risk assessment
Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.
The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician’s standard workflow.
As result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola.
Reading both these releases it seems clear that while the physicians tending the patient were able to access the nursing notes they were not forced to and so, when confronted with - on the second occasion - with an obviously ill man - there were other clinical priorities that needed to be addressed.
Given that it was possible to quickly remedy the display issue I think it is likely the way the system was operating was a configuration choice made during implementation.
What I take from to story is that this outcome provides a wonderful lesson on just how hard it can be to anticipate, in advance,  when such decisions might just provide harm and the possibility of major clinical consequences.
I also have no idea how to identify such subtle ‘black swan’ events in advance and so would suggest the best that can be done is to share what has happened widely so the lesson is learnt as widely as possible. Maybe a fix that allows any responsible clinician to flag a finding on any screen as needing to be seen by all carers to be highlighted on the entry screen might be worth considering.
The bottom line to me is that you can’t anticipate all contingencies so continual learning is crucial.

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