Tuesday, January 12, 2016

How Safe Are Electronic Health Records?

The answer to question posed in title is: No one knows because it may be unknowable  because of complexity of medicine,  EHR use in severely ill patients with multiple conditions,   and multiple drugs administered by a myriad of clinicians in a myriad of different diseases and circumstances.

But Mark L. Graber, MD, and 3 coauthors  make a stab at coming up with an answer by examining malpractice claims involving EHRs ( Mark Graber, MD, et al, ”Electronic  Health Record – Related Events in Malpractice Claims, “ Journal of Public Safety, 2015).  Also see Ross Koppel,  “What Do We Know about Electronic Medical Records? The Healthcare Blog,  January 10, 2015).

Why do EHRs generate so many errors – some of which result in patient harm and fatalities?   The problem, according to Koppel,  is “clunky and user-hostile interfaces and the lack of interoperability,” rather than “user error.”

In any case,  here is a list of EHR errors culled from malpractice claims.   These errors undoubtedly  represent  only 1% to 2% of  EHR errors.  Most errors never eventuate in malpractice claims.   Most patients and physicians are unaware an error has occurred

Graber’s Case Examples of Health IT Related Errors, by Category Type 

    1.      Fentanyl order altered by a decimal point; patient died.
    2.      Insulin order defaulted to wrong preparation (long vs shortacting).
    3. Fentanyl overdose resulting from failed auto-deletion of earlier orders of a lower dose.
                4. The EHR automatically “signed” a test result when in fact it had not been read; Patient did not receive results of co-existing liver cancer and was treated for lung cancer only. Routing of electronic data
    5.      Order for blood delayed reaching lab; patient expired before blood arrived
    6.      Critical blood gas value misrouted to the wrong unit; patient expired from respiratory failure.
    8.      Critical ultrasound result routed to the wrong tab in the EHR; MD never saw the result until a year later; patient experienced delayed recognition of cancer.

              8. Abnormal cardiac ultrasound results misrouted, would have prompted anticoagulation; patient died of stroke.System dysfunction or malfunction

    9.       Multiple reports of system being “down,” staff unable to access information; In one case, medication reconciliation could
    not be completed, resulting in an injurious medication error.

    10.  Computer crash caused loss of colonoscopy results; follow up delayed and next study disclosed colon cancer.

    11.  Nursing staff unable to locate a previous nursing assessment and vital signs; RN asserted that the EHR had just ‘gone live’ and
    kept ‘crashing’; delayed recognition of patient’s deterioration.

    12.  MD not able to access nursing ED triage note, which would have changed management; patient died of subarachnoid hemorrhage.

    13.  Fetal demise followed by consent for “limited” chromosome testing. Pathology unable to access the specific order, so didfull chromosome studies not consented by the family
    14.  Delayed diagnosis of lung cancer; Primary care provider could not access radiology studies at the time of patient visit; paper
    results filed without the MD seeing these, staff believing the
    results were available on line.

    15.  OB patient requested tubal ligation at the time of her 4th planned Caesarian section. Noted on office record but not integrated
    with the delivery room system. Covering MD delivered
    the baby but did not know\see the request for tubal
    ligation; Patient became pregnant 6 months later.
    Lack of or failure of Alert/Alarm/Decision Support

    16.  Pathology report of adenocarcinoma delayed in reaching patient’s chart until after inpatient discharge and no alert sent
    to patient’s physician; delayed diagnosis of cancer.
    Fragmented information

    17.  Test results in multiple locations; failure to note overall decline of vital signs and lab tests; patient died of sepsis.

    18.  Positive test result for cervical cancer entered into problemlist; MD expected it to be in EHR test result section; error not discovered
    until patient’s visit a year later.
    19.  RN entered Haldol order as 5.0 mg instead of 0.5 mg; MD meant to sign off on lab results, but signed off on the wrong
    order by mistake.
    All other
    20.  Pt complained of “sudden onset of chest pains with burning epigastric pain, some relief with antacid”; Complaint field
    was too small; entry noted only as “epigastric pain”; no
    ECG done; patient experienced a cardiac event days later.

    21.  Lack of follow up of abnormal PSA; visit notes were sparse due to limited text fields and use of a system that referenced
    problems by a number, not text.
    22.  User-Related IssuesUser errors – miscellaneous

    23.   Electronically signed discharge order omitted patient’s Coumadin; patient admitted with stroke.

    24.   Verbal order for morphine entered without upper limit defined; patient become obtunded and expired.

    25.  Results of positive test for C difficile not noticed; 7 day delay in starting treatment.

    26.  MD unable to find pathology report in the EHR; called Pathology to get a verbal report, which was a normal result from the
    wrong patient; real patient died of cancer 3 years later, original
    report was abnormal.
          27.Hybrid health records/Conversion issue
          28. Medication reconciliation list did not include Sotalol; resident copied the ED medication list; patient went into Afib. The EHR did not list medications from the prior admission
    and did not interface with the inpatient unit.

        29 Patient underwent colonoscopy for bleeding per rectum but exam was incomplete. MD changed EHR’s which didn’t convey
    the incomplete exam; patient had delayed diagnosis of colon

    30. Pediatric patient received ampicillin in the ER despite known allergy, which had been documented in the paper record but
    not uploaded into the EHR.
    Incorrect information

    31. Facility with new EHR dosage of Benemid copied over from paper record incorrectly; patient received double doses, developed
    seizures and died.

    32. Patient previously on anticoagulation admitted for GI bleeding; MD intended to discontinue the anticoagulant but mistakenly
    clicked on “continue Lovenox for home use”.\\

    33. Ultrasound results never scanned into the EHR; delayed diagnosis of thyroid malignancy.

    34. MD intended to order Flonase accidentally selected Flomax from a drop down menu.
    Prepopulating; copy and paste

    35. History copied from a previous note which did not document patient’s amiodarone medication; delayed recognition of amiodarone

    36. Patient was to receive 6 injections of a medication; The EHR reflected 66 injections based on use of wrong template.

    37. Incorrect conclusion that patient was on indomethacin when it was automatically pulled forward from an outdated medication

    38. Covering obstetrician did not have EHR access and could not access clinic notes documenting abnormal fetal size; stated he\she never received training or password.

    39.  failed to appreciate abnormal test results; CT results were placed in the new EHR but MD assumed he’d receive a
    paper copy.

    40. Amoxicillin ordered for patient allergic to penicillin had allergic reaction; MD over-rode the alert.

    41. Oxycodone allergy overrode by MD which removed it from allergy list.

    42. Alerts on abnormal blood culture ignored;





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