healthy4u: medical errors

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology. The first case involved a medication error (from a 'miscommunication between doctors and nurses', an infusion pump snafu, and failure to perform obvious follow up labs;  if health IT was involved it would not surprise me).  The second case involved alarm fatigue. These amounts are interesting considering the age and condition of the patients. 1.  <a href="http://www.lubinandmeyer.com/cases/medication-error.html">http://www.lubinandmeyer.com/cases/medication-error.html</a> <blockquote class="tr_bq">Medication Error Lawsuit against MGH Settles for $1.25 Million The plaintiff’s decedent was a 76-year-old woman who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times too much medication which resulted in uncontrollable internal bleeding and her subsequent death. Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia.</blockquote> and 2.  <a href="http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html" target="_blank">http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html</a> <blockquote class="tr_bq">Mass. General Hospital 'alarm fatigue' lawsuit settled for $850,000 BOSTON (AP) — The family of an 89-year-old man who died at Massachusetts General Hospital when nurses did not respond to alarms on his cardiac monitor has settled its case against the hospital for $850,000.</blockquote> I see potential lessons for at least two healthcare stakeholders in these cases: Hospital executives:  bad technology is not your friend.  get it right before rolling it out, with robust, validated safeguards, to save lives - and to save your organizations from costly litigation and reputational damage. Clinicians:  bad technology is your enemy.  While hyper-vigilance is mentally exhausting, that's what's required to avoid the fate of the patients - and the clinicians - in the above cases. Reporting bad technology and making sure the problems are remediated promptly, not glossed over, is equally essential. Note: my interpretation is that both technology and people issues probably played a role in both these accidents, based on my own knowledge and experience, but that is of course a personal opinion.  -- SS

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology. The first case involved a medication...

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Is Healthcare IT a Solution to the Wrong Problem?

In a study published in the Nov. 25, 2010 New England Journal of Medicine entitled "<a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1004404">Temporal Trends in Rates of Patient Harm Resulting from Medical Care</a>", Landrigan N Engl J Med 363;22, it was found that medical error rates were not dropping: <blockquote>In a study of 10 North Carolina hospitals [from January 2002 through December 2007], we found that harms remain common, with little evidence of widespread improvement. Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time. </blockquote> Unfortunately, I don't believe that the article differentiated between computerized hospitals and paper-based ones. Nor were the subject hospitals selected on the basis of computerization or non-computerization: <blockquote>We conducted a retrospective study of a stratified random sample of 10 hospitals in North Carolina ... ... All acute care North Carolina hospitals listed in the American Hospital Association (AHA) database except those providing exclusively pediatric, rehabilitation, or psychiatric care were eligible for selection for the study. These hospitals were stratified according to the AHA’s definition of the facility as small, medium, or large; urban or rural; and teaching or nonteaching. The number of hospitals that underwent randomization for inclusion in each stratum reflected the proportion of national discharges from that type of hospital. If an invited hospital declined to participate, another closely matched hospital was randomly invited to participate in its stead.</blockquote> While the extent of EHR/CPOE and other clinical IT adoption was not measured, some of the hospitals studied would likely have adopted and/or been using clinical IT in various capacities during the study period. The IT might have been expected to contribute to lower error rates over time. Although that is admittedly speculation, there is a more important point to be made. Many of the identified errors seem to have little to do with record keeping, but instead with human factors. From the New York Times article "<a href="http://www.nytimes.com/2010/11/25/health/research/25patient.html?_r=1&hp=&pagewanted=print">Study finds No Progress in Safety at Hospitals</a>" covering the NEJM article: <blockquote>... Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small and teaching and nonteaching medical centers ... Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during surgery, serious breathing trouble caused by a procedure being performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve and vaginal cuts caused by a vacuum extraction device used to help deliver a baby. The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the failure of hospitals to use measures that had been proved to avert mistakes and prevent infections from urinary catheters, ventilators and lines inserted into veins and arteries. </blockquote> The chart of "harms" in the article, both those deemed "non-preventable" and those deemed "preventable" reads like a textbook of medicine, e.g.: <blockquote>Cardiac arrest, shock, myocardial ischemia, acute respiratory failure, acute renal failure, hemorrhage, thromboembolic venous event, hematoma, pancreatitis, ileus, stroke or intracerebral hemorrhage, withdrawal symptoms, catheter-related bloodstream infection, urinary tract infection, surgical-site infection, clostridium difficile colitis, surgical anastomosis failure, wound dehiscence, failed procedure, unplanned return to surgery, fetal neonatal complication associated with delivery, hypothermia, pressure ulcer, catheter complication, etc.</blockquote> It seems unlikely a missing or illegible chart was the cause of many of these adverse events. (In fact, the study was done retrospectively from the patient charts.) Thus, expectations for major quality improvements in healthcare from the hundreds of billions spent on health IT might be vastly overstated based on false assumptions about the causes of adverse events. Many of the above adverse events seem not highly amenable to correction via cybernetic information retrieval systems. They might be amenable, though, to improved nursing and ancillary staffing (perhaps I should say 'elimination of understaffing'), decreased work hours, improved CME, and better supervision of trainees ($100's of billions of dollars being spent for IT would surely buy a lot of those items). What I found striking was this: <blockquote> “A third of the errors in the intensive care unit disappear when residents work 16 hours or less,” Dr. Landrigan said, although he noted that senior residents often work longer hours.</blockquote> That being the case, health IT that created heavier workloads and cognitive overload of residents already struggling under sleep deprivation might actually increase the risk of error. It would seem national healthcare IT may be a 'solution' to the wrong problems in 2010. We perhaps should better be focusing on human problems not amenable to cybernetic intervention before we start a national medical IT experiment, in the hope that major changes will somehow be effected by the magic of computers. -- SS

Is Healthcare IT a Solution to the Wrong Problem?

In a study published in the Nov. 25, 2010 New England Journal of Medicine entitled " Temporal Trends in Rates of Patient Harm Resulting...

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Cannot Get Away From Medical Information Errors, Continued

In "<a href="http://hcrenewal.blogspot.com/2007/10/this-informaticist-cant-escape-clinical.html">This informaticist can't escape clinical IT issues even on personal business</a>", I observed that I encountered HIT informational issues even in my own family matters, when least expecting them. I've had a few incidents since then, generally each time I've taken relatives to the hospital as a medical advocate. It seems every time I step into a hospital as a medical advocate such issues arise, whether they be complaints from staff about IT, my mother being prescribed an IV antibiotic in the ED that an hour before I'd told the intake nurse she was severely allergic to, that fact being dutifully entered into the EHR - or as in the case below, outright errors regarding surgical procedures. Either medical information errors follow me around, or they are more common than I realize, because I just spent a few days as a medical advocate for a very long and dear friend. She had a suspicious thyroid nodule found at the time of exam for excision of a small breast carcinoma. She was set to have a thyroidectomy at a major NYC hospital with relatively advanced HIT capabilities and large endowments from very wealthy contributors, whose paintings hang in the lobbies (and where some high level informatics professionals are involved in clinical IT projects). When I arrived the evening prior to surgery, my friend showed me her pre-op instructions. They were printed out in a neat and organized fashion, and she'd shown me the calcium supplements she'd purchased as the instructions advised. "Calcium supplements?", I asked... The computer form, properly labeled with her name and ID and the name of the nurse practitioner she'd seen for preop evaluation, was quite improperly entitled "Preoperative instructions to patients undergoing parathyroidectomy." First thing I did in the morning was insist on seeing the surgeon in person. I wanted zero chance for error. Fortunately, the surgeon was familiar with her case and knew this was an error. Suppose, however, the surgeon was not so knowledgeable about the patient, or unavailable, or called away for some emergency and someone else filling in? I do not know if the error was simple human error by the NP or someone prior who'd performed data entry, a wrong selection due to a mission hostile user interface in the setting of overwork, a computer error due to some cross-link between (to non biomedical personnel) two similar-sounding terms - parathyroid vs. thyroid - or some other cause. Needless to say, if this error had resulted in an unnecessary and injurious parathyroidectomy and necessity for followup thyroidectomy on a postoperative area, and had been as a result of IT problems either totally or partially , it is likely the vendor would have been "held harmless" and the defect nondisclosed to other organizations. (Anecdotally, on going to the bathroom, I also noted a group of residents on rounds energetically discussing what "template" was the correct one in which to enter patient data of some type. When I rounded years ago, I remember discussing medical issues...) While I agree the likelihood of major IT contribution to this error was low, this was a reminder of just how problematic healthcare quality can be, even with advanced IT. I think the solution is not to see IT as a panacea, and maintain adequate human involvement (with humans not overburdened feeding the bureaucratic machine) in safety issues. -- SS

Cannot Get Away From Medical Information Errors, Continued

In " This informaticist can't escape clinical IT issues even on personal business ", I observed that I encountered HIT informa...

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