New Oped on Cultural and Computer Issues in Dallas Ebola Cases

Just had this published in the Dallas Morning News with my co-editor Ross Koppel of First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.

Koppel and Gordon: Learn, don’t blame, after Dallas hospital’s Ebola diagnostic failure

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Mike Stone/Getty Images

Published: 14 October 2014 07:47 PM

Updated: 15 October 2014 05:57 AM

Whose fault was it? The doctor’s? The nurse’s? The hospital’s? The patient, for not explaining he had been close to a sick person? The electronic health record’s?

Conflicting reports abound in the press and social media about Texas Health Presbyterian Hospital Dallas’ ER staff failure to correctly diagnose the late Thomas Eric Duncan on his first visit there Sept. 25. The differing accounts have focused mostly on individual, institutional or technological culpability.

First we were told that the nurse in the emergency room hadn’t properly communicated information about the patient’s travel history to physicians. Then we were told that physicians had not read the nurses’ notes that were, in fact, entered into the hospital’s electronic health record. Then we were told that the hospital’s electronic health record would not permit the doctor to read the nurses’ notes.

As the Internet chatter escalates, people continue the blame game. For example, why didn’t the nurse arm-wrestle physicians into paying attention?

While it is too early to determine what precisely happened in this case, it is not too early to consider the critical issues it highlights. One is our health care system’s reliance on computerized technology that is too often unfriendly to clinicians, especially those who work in stressful situations like a crowded emergency room. Then there are physicians’ long-standing failure to pay attention to nurses’ notes. Finally, there is the fact that hospitals often discourage nurses from assertively challenging physicians.

Long promised as the panacea for patient safety errors, electronic health records, in fact, have fragmented information, too often making critical data difficult to find. Often, doctors or nurses must log out of the system they are on and log into another system just to access data needed to treat their patients (with, of course, additional passwords required). Worse, data is frequently labeled in odd ways. For example, the results of a potassium test might be found under “potassium,” “serum potassium level,” “blood tests” or “lab reports.” Frequently, nurses and doctors will see different screen presentations of similar data, making it difficult to collaborate.

Another technological issue is the flatness of electronic records: Much of the information looks the same — a series of boxes to check and pre-formatted text that makes highlighting an urgent or important issue difficult. Electronic records, with their cut-and-paste functions, create what doctors call “chart bloat.” The announcement that Duncan’s electronic records totaled 1,400 pages illustrates this phenomenon. Poor record presentations may well have contributed to the hospital spokeswoman’s initial statement that Duncan’s temperature was only 100.1, when in fact the hospital’s records show it increased from that to 103 by the time Duncan was discharged four hours later.

All of these computer problems probably exacerbated human ones: In their medical training, physicians seldom receive sufficient guidance on the importance of consulting with or soliciting information from nurses. As Claire Fagin, dean emerita of the University of Pennsylvania School of Nursing, has pointed out, physicians are not socialized to consult with bedside nurses and often refer to nursing notes in the most disparaging terms.

Finally, the Dallas case highlights another serious patient safety problem: Many hospitals have disciplined or even fired nurses who try to challenge physician practice. In 2010, two nurses were fired from a hospital in West Texas for submitting an anonymous complaint to the Texas State Board of Medicine about a physician engaging in dangerous and unethical practices in their hospital. Is it any surprise that a nurse practicing in a Dallas hospital would think twice about drawing a reluctant physician’s attention to a patient safety problem?

Duncan’s case is a tragedy reflecting a series of communication failures, both human and technological. These failures go far beyond the Dallas ER. Harm from preventable medical errors is the third-leading cause of death in the U.S. Improving patient safety across the entire health care spectrum will require the construction of medical workplaces where all clinicians can speak up, listen to each other and have health care IT that is responsive to their needs. The issue now is not to blame the staff or the electronic records at Presbyterian but to learn from their mistakes so that we don’t continue to repeat them day after day.

Health care journalist Suzanne Gordon and sociologist Ross Koppel of the University of Pennsylvania are the editors of “First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety” (Cornell University Press). Reach them at rkoppel@sas.upenn.edu or sg@suzannegordon.com.

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3 Comments

  1. No one has yet conducted an investigation to see exactly what happened. Did the Admitting Nurse who included an exclamation point after documenting Mr. Thomas Duncan’s recent travel, know that he was to be discharged ? Perhaps her shift was over by the time he was discharged ? Did she speak up? If she spoke up, what’s was the response ? It seems to me that an investigation should be the first step in figuring out what happened. Of course we know that the EHS was poorly designed, this is going on everywhere.

  2. So nice to see objective analysis instead of just finger pointing. I don’t have any answers, but do have a bit of insight into communication problems due to my experience with my mother’s stay at Dallas Presbyterian 16 years ago. When she emerged from coma, she was transferred to a regular hospital room. During the day, various specialists would make their rounds, going from room to room and spending a few minutes with each patient. During these visits the doctors would take notes and deposit them in a box outside the room for the benefit of other doctors and nurses. Since my mother wasn’t able to communicate effectively, I would often tell the doctors what had been going down and they would record this in their notes. Those boxes in the hall were supposed to be off limits except to medical personnel, but one day I noticed that no one was looking and decided to have a peek. I was astonished at the extent to which my comments to the doctors had been distorted or even completely fictionalized. It’s been too long for me to recall specific examples, but it would be along the lines of: I would tell the doctor that she was having trouble swallowing. The notes would record that “patient’s son says that she is refusing meals.” Did the doctors have too many patients? Were they not getting enough sleep? Were they just not that interested, or preoccupied with personal matters? I have no idea.

  3. So nice to see objective analysis instead of just finger pointing. I don’t have any answers, but do have a bit of insight into communication problems due to my experience with my mother’s stay at Dallas Presbyterian 16 years ago. When she emerged from coma, she was transferred to a regular hospital room. During the day, various specialists would make their rounds, going from room to room and spending a few minutes with each patient. During these visits the doctors would take notes and deposit them in a box outside the room for the benefit of other doctors and nurses. Since my mother wasn’t able to communicate effectively, I would often tell the doctors what had been going down and they would record this in their notes. Those boxes in the hall were supposed to be off limits except to medical personnel, but one day I noticed that no one was looking and decided to have a peek. I was astonished at the extent to which my comments to the doctors had been distorted or even completely fictionalized. It’s been too long for me to recall specific examples, but it would be along the lines of: I would tell the doctor that she was having trouble swallowing. The notes would record that “patient’s son says that she is refusing meals.” Did the doctors have too many patients? Were they not getting enough sleep? Were they preoccupied with personal matters? I have no idea.

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