The Doctor’s Advocate | Fourth Quarter 2015
An Ounce of Prevention
Patient harm caused at least in part by the use of electronic health records (EHRs)—or e-iatrogenesis—emerged as a factor in a closed claims study conducted by The Doctors Company. The study of 71 claims closed by The Doctors Company between 2007 and 2013 revealed that 65 percent involved EHR-related user issues, and 42 percent identified system technology design risk factors. Some claims included both user issues and system technology design risk factors.
The ECRI Institute (formerly Emergency Care Research Institute) recognized alarm hazards as the number one IT-related problem in 2015. Alarm hazards occur not only with physiologic monitoring systems,1 but also with alarm-generating devices, such as EHRs. Unfortunately, human factors may prevent healthcare providers from responding appropriately or using the alarms that are readily available to them.
EHRs have multiple benefits—from improved patient outcomes and improved care coordination to practice efficiency and cost savings. However, inappropriate use of or ignoring EHR alarms/alerts has been connected to patient harm. On the issue of over-alerting (systems generating too many alerts), Dr. Tejal K. Gandhi, president and CEO of the National Patient Safety Foundation, noted “most studies have found that only 20 percent of alerts are actually accepted,” so an important alert could be missed. She added that studies have shown that reducing the number of alerts “by streamlining the ones that you decide to alert on, by tiering, to only interrupt for things that have a certain amount of significance, you can actually reduce the number of interruptions significantly.”2
E-health data come from external sources, such as websites or through health information exchanges (hospital charts, consultant reports, and laboratory and radiology reports). Doctors also have access to data through e-prescribing community medication histories—which can expose them to liability for potential interactions with drugs prescribed by other clinicians. For example: Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another medication the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug-drug interaction, Dr. A may be liable.3
Drug-drug interaction lists are often so comprehensive and generate alerts with such frequency that they can become disruptive and annoying. Doctors may develop “alert fatigue” and ignore, override, or disable them. However, if it can be shown that following an alert would have prevented an adverse patient event, the physician may be found liable for failing to respond.4 Optimized, clinically meaningful drug-drug interaction lists that focus on a smaller set of interactions most frequently associated with harm or expert consensus lists may address this problem. However, EHR vendors may resist eliminating the low-risk warnings, fearing that doing so could increase their liability.
The following two claims illustrate some of the issues surrounding alerts and human factors.
An elderly female saw an otolaryngologist for ear/nose complaints. The physician intended to order Flonase nasal spray. The patient filled the prescription and took it as directed. Ten days later, she went to the ER for dizziness. Two weeks after that, the pharmacy sent a refill to the physician at his request. It was for Flomax—a medication prescribed for enlarged prostate—which has a side effect of hypotension. When ordering the prescription, the physician had typed “FLO” in the medication order screen. The EHR automatched Flomax, and the physician selected it without realizing the mistake. Flomax is not FDA-approved for females. There was no EHR Drug Alert available for gender. To prevent this type of mistake, the provider should have reviewed the prescription with the patient and read what was ordered. By writing the indication for the medication on the prescription, the pharmacist would have been alerted that the medication was not appropriate to the condition being treated.
A dialysis patient was transferred to a skilled nursing facility. There was an active hospital transfer order for Lovenox. A physician evaluated the patient on admission but made no comment about the Lovenox order. During the first dialysis treatment, there was active bleeding at the fistula site. The anticoagulant heparin had not been given. The nursing staff did not inform the physician of the bleeding. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient exsanguinated and expired. Experts were critical that there was no EHR high-risk medication alert. Medication reconciliation might have prevented this error.
Alerts are a necessary safety mechanism when used, heeded, and configured appropriately for your practice. Check your alerts to make sure they provide adequate information and are not overly burdensome to your practice.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.
Fourth Quarter 2015
New Early Warning Criteria Could Reduce Maternal Mortality
An Ounce of Prevention
Heed Those EHR Alerts
Government Relations Report
Damage Caps and Equal Protection: Two States, Two Views
The Foundation News
Seeking Entries for the 2016 Young Physicians Patient Safety Award
What to Expect from Litigation: Dr. Go's Perspective
The Back Page
Industry and Company News: Fourth Quarter 2015