Back to our Ebola case in Texas. Here's a report from the Washington Post:
Thursday night, the hospital said it released him because “separate physician and nursing workflows” kept physicians from seeing his travel history, which would have shown his recent presence in Liberia and possibly triggered extra scrutiny. The statement said that the “documentation of the travel history was located in the nursing workflow portion” of the electronic health records and “would not automatically appear in the physician’s standard workflow."
Blaming the EHR is like blaming the printer on a computer. Someone or some group of people made a decision at some time that the nurses' notes would not be visible to doctors.
(I wonder if the doctors asked for this "feature" at some point so the nurses notes wouldn't "clutter up" their screens.)
As I said before, this case calls for a full root cause analysis, and then we need a way to send the message of what was learned throughout the country.
By the way, a friend from Toronto reports:
In Ontario since SARS “FRI Screening” – Febrile Respiratory Illness Screening is mandatory at ED triage. The process is flexible and can easily be adjusted to add specific questions for new outbreaks, so the public health and ID experts can just tell us to ask about travel to Saudi Arabia for MERS or specific parts of West Africa for Ebola, we amend the WORD document and produce a new version of the screener, and all the nurse has to do is comply with what they always do – ask the questions on the screener and report a “failed” screen and take the indicated action. It’s a “system” that works extraordinarily well.
Thursday night, the hospital said it released him because “separate physician and nursing workflows” kept physicians from seeing his travel history, which would have shown his recent presence in Liberia and possibly triggered extra scrutiny. The statement said that the “documentation of the travel history was located in the nursing workflow portion” of the electronic health records and “would not automatically appear in the physician’s standard workflow."
Blaming the EHR is like blaming the printer on a computer. Someone or some group of people made a decision at some time that the nurses' notes would not be visible to doctors.
(I wonder if the doctors asked for this "feature" at some point so the nurses notes wouldn't "clutter up" their screens.)
As I said before, this case calls for a full root cause analysis, and then we need a way to send the message of what was learned throughout the country.
By the way, a friend from Toronto reports:
In Ontario since SARS “FRI Screening” – Febrile Respiratory Illness Screening is mandatory at ED triage. The process is flexible and can easily be adjusted to add specific questions for new outbreaks, so the public health and ID experts can just tell us to ask about travel to Saudi Arabia for MERS or specific parts of West Africa for Ebola, we amend the WORD document and produce a new version of the screener, and all the nurse has to do is comply with what they always do – ask the questions on the screener and report a “failed” screen and take the indicated action. It’s a “system” that works extraordinarily well.
This is not at all surprising to nurses, who are quite capable of gathering a complete history which is often then ignored. I have worked in Harvard hospitals where the nurses' notes are entirely separate from the "progress notes" of the doctors. Who is more aware of the patient's prgress than his/her nurse? Fortunately, I now work in the most collaborative institution in Boston.
ReplyDeleteOddly enough I feel as though the nurse should have used some semi critical thinking prowess they like to tout. Hmmmm, sick-->recent west Africa travel (assuming they know where Liberia is)-->probably warrants more than documentation on the admission navigator. Something like I don't know, a call to the physician, OR maybe even a face to face conversation (the horror). EHRs DO NOT REPLACE YOUR BRAIN. A modicum of common sense would have prevented this. Also when did physicians completely cede H&Ps to nursing? The really cherry on top is the fact he was sent home with antibiotics. Good snapshot of what's wrong in healthcare: communication, handoffs/transition, no responsibility by providers, misuse of medications. Great case study. Do I believe anybody did this purposefully? Of course not, but there are people in positions they probably shouldn't be without more training.
ReplyDeleteI'm not ready to make judgments about anybody's performance. We don't know all the facts. I'm hoping, as stated, that the hospital will be forthcoming and help other places avoid this set of errors.
ReplyDeleteAs to training, the great basketball coach John Wooden used to say, "You haven't taught till they've learned." Good training takes two, the learner and the teacher, and we often blame the learner when it is often the problem of the trainer.
To be honest though, how as a healthcare provider can you not be aware of Ebola. Hospital training or not? There is obviously a lack of critical thinking displayed. If the story THR is telling is true. If there was no communication beyond documentation in the chart there is a huge problem.
ReplyDeleteAll I can say is that, having visited hundreds of hospitals, I could imagine variants of this story happening in a lot of them.
ReplyDeleteWithout making any excuses for this case, we need to understand that the culture in many hospitals is to discourage critical thinking by front line staff. Old cultural and hierarchical patterns die hard.
This is why I have been wary of health official optimistic comments' that "we don't have to worry in America."
My philosophy is that healthcare isn't fast food, being nice isn't good enough. You need to be competent and kind. We deal with people in their toughest hours and as I manager I have a responsibility to the patients at my hospital to provide the best possible care to the patients I serve. If somebody isn't cutting the mustard I need to try and help them. If they refuse help or accept help and still don't meet the standard, I have a duty to those patients to bring somebody in who is more capable.
ReplyDeleteTouche. I sometimes forget how lucky I am to work at a place which really embraces the front line staff thinking critically. Totally agree on being wary. Don't underestimate our level of screwed upness.
ReplyDeleteYou know, if the doctor is not going to read the nurses' notes then s/he needs to ask the travel question himself, doesn't s/he. I would be embarrassed to offer such an explanation.
ReplyDeleteWithout knowing the details of the situation it is hard to cast individual blame, though that doesnt mean none would be revealed on investigation. Who knows what the shift was like for the nurse and physician, and what barriers to accessing each other either in person or through record systems they faced. Would be great that all frontline workers had the luxury and time for redundancy in evaluation, but not always the case. What is clear is that there is opportunity for systems improvement to facilitate information sharing, and a chance to evaluate and discuss culture.
ReplyDeleteAs a non-medical person, I have to wonder why the nurse asks questions and takes notes if the physician won't see them or won't look at them. If I tell the nurse something that I deem to be important, I assume that the doctor will also be made aware of that and I won't need to repeat the information. In fact, I may not be able to repeat or even remember all the important details. After all, I'm at the emergency room (or department) because I am seriously compromised in some way.
ReplyDeleteHave any of you actually sen the EMR work product? Rather than the traditionally organized format the pages go on in this sort of format:
ReplyDelete0724 RN reports blood pressure 156/79, p 67
0725 Pt checked.
0726 menu given to patient
0729 CT ordered, diet held.
0732 Blood drawn.
0734 RN smith in for detailed history? PT appears comfortable pain scale 1-on 1-10 scale
And on and on for pages. Just try to cull valuable info from these reports. But, like Ragu, it's in there.