Vol. 28 September 1, 2010 Computer Error or Patient-Centered Care?

September 1, 2010

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually”  because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me.  She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?

As a physician, I am more informed than the average patient. As the retired Medical Director of the hospital where I was receiving the treatment, I knew and had good working relationships with my nurses and the pharmacist. As a physician seeking clarification about administration of their drug, I was accommodated and happily helped by the drug manufacturer. This process involved several discussions, local and long distance phone calls, sending of faxes, reviewing of minutes, and patience on the part of both providers and patient over several days; all for a rate of 4 1/2 rather than 6 hours for a just single medication. Was this negotiation worth it?

Don Berwick “uses his own wits to safeguard against errors” and now urges the adoption of patient-centered care to restore his dignity as a patient in the current medical world where “provider trumps patient” almost every time. (2) Negotiation between patient and provider from EQUAL bases seems to be the essence of patient-centered care.  The line between requesting and demanding can be a thin one. We successfully avoided defensive stances and threatening attitudes and never felt that we were engaged in a “dispruptive shift in control and power.” (3) Is it reasonable to expect the average patient and the busy provider to conduct such successful negotiations most of the time? That is a tall order, but I hope that healthcare systems will be able to  support the process without bogging down the providers and frustrating the patients.

References:
1.  “Patient centered care means meeting patient’s needs and preferences through shared informed decision-making which will reduce unneeded and unwanted services” – See Institute of Medicine, Institute for Healthcare Improvement, Robert Wood Johnson Foundation, The Commonwealth Fund, The Joint Commission, and Patient-Centered Outcomes Research Institute websites and publications.

2.  Remarks by Don Berwick before the plenary session of  the International Forum on Quality and Safety in Health Care, Berlin 2009    http://www.youtube.com/watch?v=SSauhroFTpk

3. “What ‘patient centered care’ should mean: Confessions of an extremist.” Don Berwick, Health Affairs 2009 Jul-Aug 28 (4)


Vol. 27 August 15, 2010 No One Is Perfect, Not Even Computers.

August 10, 2010

My last post described how a precisely regimented dosage of intravenous medication delivered to me over six hours by a state-of-the art computer actually depended on the existence (and the survival for 6 hours) of a handwritten yellow Stickie hanging on my IV pole. I write this post as a recipient, certainly not a victim, since no harm occurred, of a “care error” caused by a computer.

After my first infusion I grumbled to my physician that it had taken 6 hours, and that the package stuffer the nurse gave me recommended about a 2 hour infusion for someone my weight and age. He was surprised but responded, “Those nurses are really good. They probably have more information about the drug. I would go with what they say.” So I called the Head Nurse in the Infusion Center. She told me that the infusion rates come from the computer. “How does the computer know them?”, I asked.  She responded, “The Hospital Pharmacy Committee puts them in.” I called the Chief Pharmacist, noted the difference between the package insert and the computer recommendations, and asked him to review the information because I would sure like to spend just 2 hours off my boat rather than 6 for the next treatment. He contacted me a couple of days later to tell me that that medication infusion rate had been entered into the computer several years ago and was based on data from the one manufacturer of the medication. “There are now three manufacturers and two different concentrations. Each one has different infusion rates. Yours could go in over 2 hours. I will take care of updating the computer’s recommendations for your medication before the next treatment.”

The Institute of Medicine describes a medical error as “following a wrong plan of care or not completing a correct plan of care”. My computer-associated medical error was caused by “failure to update reference information”.

Do computers cause errors? The FDA maintains a data-base that categorizes voluntarily submitted adverse events associated with thousands of medical devices. Only five of the categories have the word “computer” in it. The Huffington Post made a considerable effort to analyze the most recent year’s findings in this data base and found 237 incidents that were related to health information technology. (1)

Six deaths were associated with computer adverse events. Except for two hospital-wide computer system crashes which delayed medications (both in 2006 in Cerner installations) the events included well recognized causes of NON-computer medical errors: delay in sending an x-ray image to another facility, a physician missed reading a significant “addendum note” on another physician’s progress note, an incorrect patient identification on an xray film, and an incorrect mixing of a chemotherapy solution.

Forty-three injuries associated with computer adverse events were reported. Many of these involved incorrect manufacturing of intravenous solutions rather than incorrect computer-directed delivery as well as incorrect dates, patient identification, or study type in radiology filing systems (PACs). These radiology “errors” became “injuries” when the errors were not perceived by human readers using multiple display screens, multiple screens,  screen short-cuts, etc.

Studies to date of computer errors in clinical care have by and large identified the computer/human interface as the most frequent cause of error: transcription errors, misreading of displays, mis-navigation among screens,  ignoring alerts, overriding warnings or alerts, failing to update reference and resource information. It is comforting to know that very few of these have led to harm because most of these are recognized as errors by trained clinicians before harm occurs. There is little data currently to suggest that we are just seeing the “tip of a gigantic iceberg.” Even the harshest critic of UK’s attempt to implement a nationwide EHR has been focussed on the business plans, difficulties of implementation, and cost. (2)

Several years ago a banker spent a day shadowing both an internist and a surgeon at our hospital as part of a Doctor-For-A-Day program and summed up his impression as: “A doctor’s  job seems to be a day-long search for credible data.” As long as we have well-trained clinicians providing our care, the help that computers will give them, and us as patients, in finding credible data will far out weigh any of the “new-found errors” (3) that will surely emerge as the new technology is implemented. The greatest threat to medical safety from computers will come from our trust in them, thinking that they are always right. A vigilant, skeptical clinician, and patient, is still the best defense against any subsequent harm from “computer error”.

References:

1. The Health Care Blog, “Do EHRs Kill People”, June 11, 2010, Margalit Gur-Arie
2. http://hcrenewal.blogspot.com/ – Health Care Renewal – a blog “addressing threats to health care’s core values, especially those stemming from        concentration and abuse of power”.
3.National Research Council, January 2009


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