Medical Malpractice Bulletin – March/April, 2013

Perspective: 1/3 of physicians miss test results
Charles A. Pilcher MD FACEP

One third of physicians surveyed admit to missing a test result because of information overload linked to their Electronic Health Record (EHR).

It’s called “Alert Fatigue,” and it’s a growing challenge. Most EHRs have built in alerts, designed to keep physicians from making mistakes: Examples:

  • “Patient due for repeat mammogram in 4 weeks.”
  • “Cephalexin prescribed. Allergy to penicillin. Click ‘override’ to continue.”
  • “Last Percocet prescription yesterday. Do you wish to proceed with refill?”
  • “The dose prescribed is out of range for a 2 year old.”
  • “Critical value: Potassium 1.5”
  • “Please see biopsy report.”
  • “Telephone call from patient. Abdominal pain worse.”

In a survey by Singh et al published in JAMA Internal Medicine  of 2600 Veterans Administration primary care physicians:

  • 55.6% reported that their EHR made it possible for practitioners to miss test results.
  • 69.6% reported receiving more alerts than they could handle
  • 86.9% perceived the quantity of alerts they received to be excessive,

Most important, 29.8% reported having missed results that led to delays in care.

The median number of alerts PCPs reported receiving each day was 63.

The net result makes one wonder, “Is an EHR worth it?”

EHRs are supposed to increase patient safety, improve quality, and make physicians more efficient. However, in a 2012 study by Medical Economics, productivity declined an average of 30% during the implementation period, was as high as 50% in some, and arguably may never produce the efficiencies touted by consultants, vendors, and the government.

And with the metadata provided by computer audit trails available for most EHRs, it should be easy to show who saw an alert, and when.  Or who did not see it?

Perspective: Why doctors make mistakes: Part II
Charles A. Pilcher MD FACEP

A study published in JAMA Internal Medicine reveals that the most common causes of medical error resulting in delayed diagnosis and patient harm are “cognitive errors” completely within the physician’s control.

Problems with doctor-patient encounter cause most primary care diagnosis errors. On retrospective review of patients requiring an unplanned admission or repeat clinic visit, the causes were found to be:
* 57% – Failure to order tests indicated by the history and/or exam
* 56% – Failure to obtain a complete or appropriate history of the presenting problem from patient or family member
* 47% – Failure to do an appropriate physical exam related to the presenting problem

Most errors result from simply failing to gather the appropriate data to reach an informed conclusion, or failure to communicate, and not from “system” or “technology” issues. In general these preventable errors led to significant patient harm.

This article is worth keeping in one’s archive of the “basic science” of medical malpractice. When mistakes appear to have been made, understanding how common they are and why they are made can help attorneys on both sides during litigation.

Click here for the complete study. For more on physician errors, see the earlier Medical Malpractice BulletinPerspective” discussing various “cognitive biases”  and how they can lead physicians to erroneous conclusions.

“You can admit a patient, get 3 sets of enzymes and prove that the they have not had an MI, or you can discharge them, and they can prove that they have.” Mel Robinson, circa 1985

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