Thursday, November 21, 2013

There Are Some Really important Lessons That Need To Be Learned From This.

This appeared a little while ago.

EHR workarounds, poor documentation cause deaths at Memphis VA

October 29, 2013 | By Marla Durben Hirsch
The inadequate use of the Memphis VA Medical Center's EHR led to the deaths of at least two patients in its emergency department (ED), according to a new report by the Department of Veteran's Affairs' Office of Inspector General (OIG).
The OIG, which conducted its inspection after receiving a complaint of three patient deaths, found that in one case a nurse had inputted into the EHR the fact that the patient had an allergy to aspirin, but that the physician bypassed the EHR and hand-wrote an order for an anti-inflammatory drug that is contraindicated for aspirin. Had the physician order been inputted into the EHR, pursuant to hospital policy, a drug alert would have automatically been generated.
The patient went into full cardiac and respiratory arrest soon after receiving the drug and died eight days after the family agreed to take him off life support. In another case, incomplete and conflicting EHR progress notes caused a delay in the treatment of a patient's high blood pressure. He was later found unresponsive and died the next day.
Lots more here with a link to the report.
This report really needs careful review. What we seem to be seeing here is people using the technology badly. Seems that at least 2 areas to be addressed are the level of user training and the workflow characteristics of the EHR systems.
More to come I am use as we see electronic records more widely used.

1 comment:

InformaticsMD said...

or people using bad technology.

One should not have to work around something that is not in their way.


Definition per Dr. Jon Patrick and me:

Good Health IT ("GHIT") provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.

Bad Health IT ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.