Medical Malpractice Bulletin – March, 2017

Electronic Health Records (EHR’s): A “critical” review of “click-tation”

By Charles A. Pilcher MD FACEP

The purpose of a medical record is to record information about a patient for future reference or to communicate information to other caregivers. EHR’s have failed at both. “Click-tation” has replaced information transfer. A handwritten entry is rare. Within hundreds of pages of “documentation,” only 1-5% may be useful information. In 30 minutes recently, I was recently able to eliminate over 2300 pages of a 2402 page medical record as absolutely useless. This “Perspective” summarizes a Medscape article by Neil Chesanow, reviewing 8 ways that EHR’s pose a danger or can be a factor in a medical malpractice lawsuit. Copy/Paste is the most pervasive. To read more, click here ->

A danger of e-prescribing

Physicians are routinely transmitting patient prescriptions directly to pharmacies electronically, aka e-prescribing. While this eliminates the problem of poor handwriting and simplifies both the doctor and patient experience, e-prescribing has its dangers. One of them is that it is still possible to select the wrong drug or dosage from a drop-down menu. Another is the possibility of fraudulent prescribing if a computer is left open with a physician’s password (see above.) But a recent JAMA piece pointed out a less obvious problem: how and when to stop a medication. If a drug is stopped or a patient is switched to another medication, what is the process for assuring that duplication doesn’t occur. What if a patient taking Coumadin is switched to a platelet inhibitor like Plavix? What if someone other than the patient manages their medicines? How do we assure that a drug gets cancelled. Failing to do so can lead to significant potential patient injury. A JAMA article by Shira Fischer and Adam Rose describes ways in which patients can end up on more medicine than intended because of the technical difficulty of cancelling an e-prescription. Anyone with an interest in pharmacy and the role of electronic prescriptions in patient care would be enlightened by this article.

Physicians don’t know the benefits or harms of tests and treatments

Hoffman and DelMar published a review in JAMA Internal Medicine addressing how well physicians understand the various benefits and harms of clinical tests and treatments. The risks and benefits of procedures like hysterectomy or prostatectomy, cancer screening, prenatal testing and various medical imaging studies were assessed. The bottom line is that physicians (and patients) always overestimate the benefits of doing something and underestimate the risks. Inaccurate perceptions about the benefits and harms of interventions are likely to result in suboptimal clinical management choices. An earlier report based on a survey by Wegworth & Gigerenzer in the same journal’s “Less Is More” column addressed how aware physicians are of the various benefits and risks of health screenings. Far less than 50% of physicians were able to estimate the risks of over-diagnosis for mammograms and PSA tests, or discuss those risks with patients. Bottom line: Physicians’ lack of knowledge leads to over-diagnosis and over-treatment. A short summary of the latter report can be found in Health News Review.

Diagnostic Errors Fishbone Diagram

I thought you might like to see the “Diagnostic Errors Fishbone Diagram” developed by Dr. Robert Trowbridge and colleagues at the Maine Medical Center. At first glance it appears cumbersome, but as one reads through the details, you’ll be surprised to see how it represents the errors found in medical malpractice lawsuits in an almost uncanny fashion. Whether defense or plaintiff, this diagram can really help one focus on the various causes of medical error. (A resulting “Diagnostic Error” would be to the far right side of the fishbone.)Diagnostic Error Fishbone

 

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