Perspective: Why physicians make mistakes – deja vu all over again
By Charles A. Pilcher MD FACEP
April, 2015
This newsletter has frequently posted articles and “Perspectives” on what leads to physician error. Now a fascinating JAMA editorial on physician mistakes sheds light on the progress we are making (or not making) in improving patient safety. Beginning 100 years ago with Dr. Richard Cabot’s reports of mis-diagnoses found on autopsy, the author summarizes several causes of error. We assume that medicine is becoming safer and mistakes are less frequent, but is that the case? There’s a powerful punch line here. To find out what it is, click here.
EHR’s remain controversial, continue to make news
Several recent articles highlight the ongoing debate over the pros and cons of electronic health records.
- An article in Business Insurance News describes the EHR as a “shield” for physicians who diligently document their patient encounters, but a “sword” for plaintiff attorneys who know how to spot the flaws – and there are many.
- Dr. Robert Sterling, author of Keys to EMR Success, summarizes 8 malpractice dangers in the EHR in an article in Medscape Emergency Medicine. Most of these, such as careless use of templates, have been previously covered in this Bulletin but are nicely presented in this article.
- Dr. Atul Gawande, writing shortly after the Dallas ebola virus death, points out how the EHR may have played a significant role in the unfortunate discharge of the first ebola patient in the USA.
- Dr. Rick Bukata, writing in EP Monthly, discusses a series of practical drawbacks and limitations of EHR’s, particularly over-testing, over-coding and decreased time for patient contact. He also refers readers to another article by Dr. Nicholas Genes in the same publication.
- Some have chosen to use “scribes” rather than an EHR to produce the medical record of an encounter. Some are using scribes to enter the EHR data. Problems with this approach are discussed in a guest blog post in Physicians Weekly by a retired surgeon.
Bottom line: The jury is still out on whether there is more “sword” or “shield” in the EHR.
Is endovascular removal of clots a “breakthrough” in stroke care?
Several studies in the last few months are showing promising results for patients with embolic strokes or thrombotic strokes in which a clot can be retrieved. The caveats in these studies are that the newer approach is a) limited to a small subset of stroke patients (< 5%), b) continues to require early intervention (< 6-8 hours in most studies) and c) must be done at a center with a dedicated stroke team and interventional radiology. Since the vast majority of strokes occur in patients who fall outside the parameters of these studies, this approach is only a “breakthrough” for a select few. While the approach shows promise, we have yet to approach the cutoff to benefit even a qualifying individual “on a more probable than not basis.” Here are two reports on some of the studies:
- Bloomberg News article on restoring brain circulation by mechanical clot removal rather than tPA alone.
- MedPage Today article on the REVASCAT study published in NEJM in which clot removal and stenting improved outcomes.
Clarification: Suing the “team”
Last month’s post regarding the Washington Supreme Court’s analysis of a case allowing a “team” to be sued rather than a particular practitioner has been clarified by the WSMA. The trial evidence established that “the surgeons in charge of the patient’s postoperative recovery failed to meet the standard of care, which required appropriately monitoring the patient for compartment syndrome… and also failed to direct members of the hospital’s care team.” Thus, according to the WSMA’s analysis, the law still requires a plaintiff to establish a “link of a specific breach of the standard of care to an individual provider.” This “clarification” was meant to allay concerns that the Court’s decision could open entire practices to claims lacking such a link.
Constipation costs over $1 billion per year in ED visits
The American Journal of Gastroenterology published a study by Sommers et al. on ED visits for constipation from 2006-2011. It’s much more than a “pain in the arse.” It’s also a HUGE expense. In 2011 nearly a million people visited an ED in the US with a chief complaint of constipation. The average cost per visit was $2306 and the aggregate national cost was over $1.6 BILLION. Infants and the elderly had the highest frequency of constipation-related ED visits.