Do you report medical errors linked to use of your EHR? Some Rhode Island doctors did, and they seem to be paying a high price for their forthrightness.
According to a story appearing in Politico, at least four emergency department doctors at Rhode Island Hospital have received subpoenas from the state Department of Health related to imaging tests ordered mistakenly. It’s not clear what caused the problems but as the publication rightfully notes, it’s easy to click on the wrong icon or wrong patient name when using an EHR.
According to the story, a Department of Health spokesman said that the agency considers patient identification errors to be ‘never events’ and that when such errors are reported, they routinely conduct investigations into the physicians’ conduct.
Heightening the stakes involved, the hospital has been under a consent decree with the state since June after it got cited over mistakes with radiological procedures, including a mammogram, heart X-ray and invasive angiogram ordered in error, along with a wrong-side vertebroplasty. Under the terms of the decree, the hospital is required to report near misses and other patient safety issues
The consent decree requires that clinicians working in the emergency department keep no more than one patient’s record open at a time on a computer screen, which some authorities consider to be safer. (In an aside, Politico notes that recent research suggests that the one-window, one-patient approach may not necessarily be best for juggling patients in the ED.)
One physician who works in the emergency department at Rhode Island Hospital probably spoke for many when venting her frustration on Twitter. The physician, Gita Pensa, wrote that while she and her colleagues were happy to work with public health authorities to enhance patient safety but that “to punish mouse-click errors with fines and loss of licensure seems disproportionate.”
I agree with Dr. Pensa that the state’s reaction may be disproportionate. In fact, it could arguably be seen as downright unreasonable. Yes, the Department of Health needs to be cautious, particularly with a hospital already under close scrutiny, but it’s important that its efforts do more than punish the ‘guilty.’
After all, I’ve never seen a punitive approach work well in fostering long-standing process changes, as fearful, burned out physicians aren’t likely to adapt terribly well. There are probably times fines and licensure threats make sense, but certainly not when the true cause of such problems lies in poor EHR usability, which it almost certainly does.