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A Real-World Example
Part 1: Ben's Story
Ben, 80, has Parkinson's Disease, a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination. When Ben fell at home and lost consciousness, he was taken to the emergency room at a local community hospital, where he was kept for 12 hours.
Ben's Parkinson's Disease frequently causes confusion and forgetfulness, and he wasn't the best witness to what was going on around him. On the other hand, his son, Scott, who stayed with him in the ER, was an acute observer of the care Ben received. His account of what he saw and heard provided valuable information in assessing Ben's ER visit and in determining whether standards of care were met.
An ER physician assessed Ben soon after his arrival. The physician ordered several diagnostic tests to ensure that Ben hadn't had a stroke or something else that could have caused a loss of consciousness. Other than Parkinson's Disease, the ER physician could find no cause for the fall or the loss of consciousness.
As a precaution, the ER physician recommended that Ben be admitted for observation overnight. Ben and his family agreed. Unfortunately, as is often the case in today's healthcare system, the hospital did not have a bed available.
Fifty-five minutes later, one of the ER nurses came into the room to complete a nursing assessment. A nursing assessment is used to create a plan of care for a patient, to alert the staff to potential problems or requirements, and to ensure the patient's safety. Ben's Parkinson's is exactly the kind of history that a nursing assessment is designed to record. ER policy requires this assessment be completed within the first 30 minutes of the patient's arrival in the ER.
Interestingly, even though the room had a computer and computerized charting system, the nurse chose to handwrite her evaluation and Ben's medication list on a slip of paper rather than use the computer workstation in the room. This is not uncommon in facilities that use paper charts, but the installation of an electronic medical record (EMR) is designed to save this step. Unfortunately, some EMR systems are so cumbersome that it's easier and faster to handwrite information and later transcribe the handwritten information into the computer system. This happens so often in the industry that it has its own term—double charting. Double charting is time-consuming and does not capitalize on the benefits of computer-based patient charting—specifically accuracy and a reduction in workload for the staff. In its worst implementation the EMR actually slows down the process of charting by adding a step that did not exist before the implementation. Although seen frequently, not all hospitals double chart.
Scott left Ben to attend to his mother who was at home, but told Ben that he would be back shortly. Scott admonished his father to stay in the bed and not try to get up without assistance. Before he left he made sure that the call button was in reach of the bed and that Ben remembered how to use it. Satisfied that his father would be safe for the time being, Scott left the ER.
While at home Scott called the ER to get a status report on his father. The unit secretary told Scott that his father was doing well, and was up and walking around his room. Scott quickly informed the unit secretary that his father had Parkinson's Disease and that he should not be up and walking around without assistance. As it turned out, Ben had not been up and waking around; because the staff was not monitoring him, the information provided by the unit secretary was incorrect.
When Scott returned, he found Ben lying in his own urine. When asked why he hadn't called for assistance, Ben said he couldn't remember how to use the call button and that no one had come into the room to offer assistance or to check on him. Scott cleaned up his father, changed the bedding and went to the nurses' station to speak with Ben's nurse. During Scott's absence there had been a shift change, and it took Scott a few minutes to find the nurse assigned to Ben. The nurse did not know that Ben had not been checked on. She had not seen Ben since beginning her shift. Scott stayed with his father until he was finally transfered to the inpatient unit.
Ben arrived on the inpatient unit at approximately 10:00 PM, 12 hours after his admission to the ER. Although Scott was happy that his father was out of the ER and would receive better nursing care, it soon became apparent that the ER had made some critical mistakes in documenting Ben's condition. And documentation wasn't the only problem.
Ben had waited in the ER for 12 hours before finally being admitted. During that time Ben did not receive any of his regularly scheduled medications. The explanation from the ER staff was always "he'll be up on the inpatient unit soon so we'll wait until he gets there." Hopeful of a bed on an inpatient unit, Ben's son waited with him.
When the nurse did finally chart Ben's medications she made two mistakes. She noted the wrong dosage of one medication and transcribed the wrong administration time of another into the EMR. Since the ER physician did not obtain a list of medications from Ben's family the medication orders were written using the information obtained by Ben's nurse and then incorrectly entered into Ben's admitting orders.
As soon as Ben was admitted to the inpatient unit the nursing staff immediately conducted an admission assessment. Scott stayed with his father to make sure that the information the nursing staff received was correct. The nurses on the inpatient unit did a good job assessing Ben's condition, until they got to Ben's medication list. Had Scott not been there for the assessment, the medication errors made in the ER would not have been caught. But even catching the mistakes in the admission orders did not mean that the problems were over. There was one final problem to overcome.
When the medication errors were found, the nurse assessing Ben told Scott that the interface between the ER system and the inpatient system had problems. Not all the medications entered into the ER system actually made it into the inpatient system. This is, unfortunately, not an uncommon problem. Most hospitals, such as the one that Ben was in, create "work-arounds" to deal with these poorly designed systems and interfaces.
At the root of most disasters is a series of smallish mistakes that, taken individually would, not be particularly harmful but that add up to catastrophe. For Ben, a disaster was narrowly averted.
Part 2: Analysis
Paper charts are particularly susceptible to inaccuracy. At times the chart is not available to a physician or nurse at the time they should be charting, either because another staff member is using it or because the paper record simply happens to be in a different location. When the process of documentation occurs after the fact, it is easy to prepare a chart in such a way that it reflects the standard of care rather than the care as it was given. This is not to say that physicians and nurses routinely falsify records, but it recognizes the fact that the human memory cannot be perfectly accurate in recreating events as they happened.
Electronic charting, when implemented correctly, can alleviate many of these problems and provide a host of other time-saving features. A good medical record is reliable documentation of what the physicians and nurses knew about a patient, when they knew it and what they did about it. But the system must be designed correctly and be properly implemented. Both are challenges to institutions with limited IT experience.
There are two types of information that can be used to evaluate the care a patient receives.
The first is direct information. Direct information describes the actual care a patient received—the documentation of a patient assessment, for example, or orders for diagnostic tests or treatments.
The second type of information, metadata, is information that can indicate how the ER was operating at a particular time. For example, Ben's nurse did not record his assessment or medication list in the room. The electronic record shows that the charting was actually done on a workstation located at the ER desk. Other types of metadata include where a physician or nurse was located during a shift, the number of patients assigned to a physician or nurse and when certain events occurred in the ER such as change of shifts or reassignment of patients. The electronic medical record can be a valuable tool in assessing both direct information and metadata.
By looking at information in Ben's medical record, we can tell a lot about how well an ER was operating, whether it was appropriately staffed, whether Ben received the attention needed based on his condition, and whether the data in the record was accurately shared among the hospital's systems.
Analysis of the EMR clearly shows the timeline of what happened to Ben from the time he arrived to the time he was discharged from the hospital the next day. Ben's record shows that he arrived in the ER at 10:06 AM. The ER nurse did an initial triage before he was placed in a room in the ER at 10:20. The physician saw him at 10:30. He was seen by the ER physician less than 30 minutes after arrival, well within the ER's policies for an initial assessment of a patient. The ER physician ordered a CT scan at 10:40 and by 11:10 the results were available in the ER.
This was an example of excellent, well-documented medical care. But, as the record is reviewed in more detail, the quality of care Ben received rapidly declined.
The ER's policy requires that a nurse perform an assessment within 30 minutes of a patient's admission to the ER. The nursing assessment, required to ensure Ben's safety and comfort, was not completed until 55 minutes after his admission. Even taking into account the fact that Ben was taken off the unit for a CT scan, he waited for another 20 minutes after he returned before the nursing assessment was performed. These 20 minutes could have been critical. In his confused state, if Ben had been alone, he might have tried to get up by himself. Until the nursing staff made the assessment and created a plan to ensure Ben's safety, he was an at-risk patient.
The timing of Ben's nursing assessment cannot be disputed. The record clearly shows that Ben's CT scan was done and the ER physician's assessment completed long before the Ben's nurse completed the assessment. We know the assessment was handwritten and then transcribed into the EMR system after the fact. The system clearly shows that the workstation used by the nurse was not in Ben's room but at the nursing station. It is also questionable if the assessment was correct.
When looking at Ben's assessment and resulting plan of care it's obvious that Ben's care was subpar. The computer record showed the following:
- The assessment was completed late
- The assessment was transcribed from handwritten notes, which tend to be less accurate and show that the computer system was not well integrated into the ER workflow
- Ben was not actually monitored by the staff; the EMR shows that staff members were engaged in other activities in the ER during the times that Ben was supposed to be checked
As the investigation continues it also becomes clear that the computer system used for documentation in the ER is not fully integrated into the workflow and may in fact contribute to errors, such as the ones experienced by Ben.
When Scott returned he found that Ben had soiled himself and told Scott that no one had been in the room to help him. Was this just Ben's confusion or did the ER staff fail to check on him throughout the time Scott was gone? It can be easily found, on both the paper record and the electronic record, that no member of the ER staff checked on Ben while Scott was gone. While there may have been "late entries" by the staff on the paper record, the electronic record would have clearly shown when the entries were made.
The most critical mistake made was the incorrect medication list that was ultimately transferred to the hospital's inpatient system when Ben finally was admitted to a room. Since Scott stayed with his father to make sure that Ben's condition was appropriately documented, he was able to catch the mistake that may have not been initially discovered by Ben's nurse. The reason for the mistake was not transcription error. The reason for the mistake, as related by Ben's nurse, was a faulty interface between the ER system and the inpatient system. Since these two systems were provided by two different vendors, an electronic interface provides the only means to exchange information between them. These interfaces are complex, difficult to create and difficult to maintain. As we see in this example the interface did not work correctly, and although the staff was aware of the problem, the interface was still being used. Errors like this are not uncommon.
Summary
Ben was lucky to have an advocate with him during his stay in the ER. Had that not been the case, the outcome could have been very different. As it was, the errors that were made were clearly documented in the hospital's EMR. Had Ben fallen or received the wrong medication, the EMR system would have described each of the errors in detail.
EMR system also have the potential for supporting claims of good care as well. Implemented and used correctly they can prevent mistakes and provide solid documentation of a patient's condition. The use in legal discovery can be a beneficial to a patient or to a provider.
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