Monday, September 15, 2014

Doctor Errors Kill 500,000 Americans a Year

The article published last week the author claims that Doctor Errors Kill 500,000 Americans a Year
The Institute of Medicine in 1999-2000 released a report that 44,000-98,000 patients a year die as a result of medical errors.  The main categories of error at the beginning of the 21st century were diagnostic, treatment, prevention and system errors.

In this article, only about 15% of a decade later, raises that number to 500,000.  Is 500,000 accurate?  Well, that depends on how the counting is being done, as it is an inherently complicated analysis to determine whether "a specific action or inaction directly lead to a death".
Causality: is the relation between an event aka the cause and a second event aka the effect, where the second event is understood to be a consequence of the first.
A chief aspect of the complexity is the blur that naturally occurs between events that are simply associated in time, and events that are causally linked.  When events are merely associated with one another, they may appear to be causally linked because one comes before, and the other occurs after, but causation is nevertheless absent.  When events are actually linked by causality; however the earlier produces or directly contributes to the later.
Sorting this out may seem achievable, but often is not.  moreover, for the purposes of health-care analysis or litigation, it is quite easy for one side or the other to make before-after appear like before caused after.  When cause and effect are obvious then the attribution of causality is clear.  Usually this only happens in simple cause-effect circumstances.  Say a person weighs 500lbs and is known to have eaten three gallons ice cream nightly for the past 15 years.  In this care, the cause-eating ice cream- is certain without any doubt.
But in medicine, things are rarely ( or never) so simple.  For example, suppose a man presents to the ED having been brought in by rescue after a car accident.  He begins to have some chest pain, and an EKG is done, which shows an Acute MI aka heart attack.  Now what was causal regarding the MI?  Was it the physiological stress of the car accident, the psychological and physical stress of the rescue transport, or perhaps his wife yelling at him before he left home?  Could the MI have occurred before the accident, and the physiological stress of the infarction have precipitated the accident?  Or, could he have bee exposed to some drug or the substance decreased his coronary flow, and been a definitive causal factor?  In this example, no one knows, and claims of such knowing are highly suspect to be thoroughly biased, and likely influenced by funds on the table.  There are simply a panoply of associated factors present, any one of which, or any combination of which, might have been causal.  The same is true with respect to medical errors, except in this field of inquiry, causal factors within the system itself are the most dominant associated factors for which individuals in the system are frequently blamed.
Indeed those who study medical errors fully are the first to acknowledge that prevention of such errors are for the most part systemic issues.  That is, humans are simply not error free; systems on the other hand, can come much closer by putting into place checks and balances to catch errors whenever possible.
In heath-care litigation, the claim made does not take into account the complexity of determining what really caused a bad outcome.  The number claimed by the Institute of Medicine was considered outrageous at the time, and for good reason; indeed this number seems high and sensationalistic.  They clearly equated bad outcome with caused by an error in care.
The numbers are less relevant than recognizing the presence of an underlying system problem that needs fixing.  Recently, system analysis experts have working toward a plan where the individual practitioner is not the recipient of the total blame, but a pathway to fixing the problems for all involved.

Monday, September 8, 2014

8 Malpractice Dangers in Your EHR

In the 8 Malpractice Dangers in Your EHR article, the author analyzes the legal risks implicit in the use of an electronic health record.  These include:
  • The healthcare provider is legally responsible for the medical record not the vendor and/or consultant even if there is the claim of a faulty product..
  • Copy and pasting text.
  • Lack of password control.  Sharing your password may allow certain entries and/or additions to look like provider direct input.
  • Ignoring clinical decision support without careful documentation of why.
  • Customizing your electronic health record without realizing you may be affecting the main data base.  Critical pieces of data must be acknowledged not just placed in the body of the note.
  • Using the meaningful use criteria for payments may lead to a change in the standard of care.
  • Entering incorrect information due to time pressures.
  • Altering the patient-provider interaction by focusing on the computer screen, not the patient.

It is advisable any provider should read the entire article.  Most of the time, worry about these points is unnecessary.  However, the majority of lawsuits and complaints cannot be predicted in advance.  The best solution is to fully understand that every feature an electronic health record offers has some potential downside.  If aware, the provider can compensate with some explanation placed directly in the record.

The legal field is getting more sophisticated about its analysis of the electronic health record and using it to their client's advantage.  One of the huge issues is the creation of complex meandering timeline of events.  The computer documents the exact time the data was input, but does not realize when the actual events occurred.  Spending a little time on the clinical course can put large amounts of data in a logical order.

Monday, September 1, 2014

Getting the Dread On!

My long-time Emergency department colleagues collectively called the anxiety and anticipation about having to perform perfectly on the next shift "Getting the Dread On".  This implied that the worry about the stresses of the next stint could begin any time from when the last shift ended.  The definition of dread is great fear or apprehension.  Common synonyms include fear, apprehension, trepidation, anxiety, worry concern unease, angst- you get the picture. 

After reading these descriptions, one would wonder why anybody would work at this job.  We'll save that for a another blog.

Some shift work health consequences include:
  • Sleep disorders
  • Diabetes Mellitus
  • Headaches
  • Ischemic heart disease
  • Fatigue
  • Stress
  • Poor appetite control
  • Substance abuse
  • Problems with medications
  • Problems with interpersonal relationships
The biggest fear is making mistakes leading to poor patient outcomes.  This coupled with volume and performance pressures, patient satisfaction scores, the ever-looming threat of malpractice suits, and chronic self-doubt can immobilize an individual.

It is probably time to retire or find a less stressful career than Emergency Medicine if getting the dread on is a recurring theme in your life.  Fortunately, most people learn to deal with the stresses and overwhelmingly positive side to the job, and they soldier on!