Without knowing the details, but using the general scenario to sharpen our collective thinking..... One could say that this tragic error falls in the category of a critical physical exam finding, test or imaging result not being followed up and also shared with the patient. These errors happen way too frequently. I would argue that this type of error is not just a "failure to communicate" error. At the heart of the problem is the EHR. Current EHR's were mostly designed for documentation with the purpose of maximizing billing. The EHR is thus perceived to be pure drudgery for most clinicians because ultimately they are drudgery and are often not about patient care. 50 years ago Larry Weed began the discussion of patient engagement along with his creation of the Problem Oriented Medical Record. The POMR is not understood by todays doctors and it should be. Currently, (as opposed to 50 years ago) problem lists are mostly out of date past medical history lists. Dr. Weed defined a "problem" which is a symptom or complaint until there was a basis for the diagnosis. Once there is a basis for a diagnosis, a diagnosis can be listed in the problem list. A finding such as "cystic mass in right adrenal gland" would have been a problem in any medical record created by Dr. Weed's team. If you were a student, resident, nurse or physician and you did not chart a problem in one of the records for Dr. Weed's patients you would be eviscerated on rounds the next morning. Dr. Weed was a tough teacher and enforced thoroughness and reliability. He put a primacy on a thoroughness rigor over evaluation of medical students based on their exam scores. The meticulous building of a problem list is at the core of patient centered medicine. The problem list would always be reviewed with the patient at discharge. An abnormal finding or key problem result not being communicated to the patient begins with it not being recorded as an active problem.
Of course the elephant in the room is that most problem lists are not up to date and many doctors never look at them. The care team can review them and the patient should have access to them. Until we enforce thoroughness in our behavior through well maintained problem lists and 100% review with patients of their problem list at every visit and discharge.....we are going to have a broken system.
Art Papier MD
Associate Professor of dermatology and Medical Informatics
Universiyt of rochester
Thanks Art. It's also about diffusion of responsibility. If a task doesn't explicitly fall to some named individual, it belongs to no one.
Karen Cosby M.D. | Program Officer | Gordon and Betty Moore Foundation | O 650-213-3160
Completely agree! Discipline and consistency would be part of insuring non-diffusion of responsibilities.
I would love to say something about this event but I cannot since I work at the defendant institution. That being said, these sorts of errors often get blamed on individuals but are system problems. The example given earlier in the thread regarding Dr. Weed's approach, while notable for his attempts to reduce such errors, still rely on individuals and hence blame individuals (getting "eviscerated on rounds the next day"). While individuals are part of the system, focus on individuals mostly leads to failure in safety efforts. There are many opportunities to close the loop that are missed. Wish I could say more.
Open Notes is clearly a way to decrease the likelihood of an event like this from happening in the future but it is not enough to eliminate it. A large problem with Open Notes is that most patients do not read their notes. I am a big fan of Open Notes but it only will mitigate. Communicating results to patients will also mitigate but also will not totally fix the problem. Patients may hear or see abnormal test results but that does not mean they do the needed follow up. We recently published on risk factors for failure to follow up abnormal creatinine tests and patients who saw their abnormal results on the patient portal (verified electronically) were only slightly more likely to follow up. There needs to be a closed loop system where these abnormal results are tracked to resolution. Malpractice attorneys and some physicians like to consider mere documentation that patients were notified of their results good enough but it is not.
Michael H. Kanter, MD, CPPS
Professor and Chair
Department of Clinical Science
98 S. Los Robles Avenue, Pasadena, CA 91101
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Hopkins actually has open notes (MyChart in EPIC). patients can access their charts through the web. but as Dr. Kanter pointed out, they are uncommonly accessed and I suspect patients aren't always sure what to do with the information.
July 28, 2020
From an outsiders point of view, it clearly looks like the mantra for physicians is that they are the ultimate judge of what is important to someone other than themselves - the patient - and that many believe there is a no need to question their evaluation. Hence the lack of records disclosure to the patient. A typical human condition.
The challenge is to get both the clinician (team) and the patient (and family) to take responsibility for each and every patient. Not easy to do! So thinking of this as a "system" problem; if the medical "industry" each had a stake in the outcome (financial obligation to cover costs), would it not work more astutely to fix things early? As it stands today, the more billings (services), the more income. Some medical institutions have implemented a patient insurance program, accepting the downstream responsibility.
Next, take the autonomy of the physician and blow it up; it is a concept long outdated. All other critical industries are moving (have moved) to Team environments - meaning the evaluation and decisions are shared.
Is this like getting Congress to pass term limits.
July 29, 2020
Teams are not leaderless. The leader must have the mindset to solicit the ideas, knowledge and opinions and share reasoning for going down a path. The leader remains responsible to reach a decision. Team members must also take some responsibility. Many elements of medicine already function in this manner.
Patients and Families are Team Members.
One weakness of Teams is that it slows down decision making. So, in a crisis, the leader has to take the burden and act accordingly. That does not mean that a decision is not modifiable as more becomes known.