Please take a moment to read this excellent Blog post sent to my attention by Jake Poore. How many of us or our family members have had similar, but hopefully less dire healthcare encounters? How many others must needlessly die or be injured because of poor communication, fragmented records, and broken processes in hospitals and clinics?
“Just call me, Eddie”
I need to write about this, because this day still haunts me, years later. And it is amazing the clarity I still have of the entire day, of every word said, and how it made me feel.
My dad had a heart attack the same week President Clinton had been scheduled to have his heart surgery, but Clinton had to wait an extra few days until the blood thinner had left his body (important to note). My dad was on a fishing trip vacation with friends out of his home state at the time. His closest family and friends were hundreds of miles away. When he was rushed to the local emergency department and immediately admitted to the Intensive Care Unit, where the nurse gave him a blood thinner IV and said it would help with his heart palpitations. As it turns out, he had to have heart surgery, immediately, to save his life.
I flew from Florida to Michigan to be with him prior to his surgery. While he was waiting for surgery, he joked a lot with all the nurses who came into his room. Each nurse he met would call him, “Mr. Poore”, and he would immediately say, “please just call me, Eddie”. They would always reply, “Okay, Eddie. And I’ll make sure the next nurse knows that too.” Of course, the next nurse would come around and again address him as “Mr. Poore”, and Dad would reply, “Just call me, Eddie,”and this new Nurse would say, “Okay, Eddie. I’ll tell the night nurse”. They never got it right. After a while, my Dad became really frustrated and a bit concerned about his care team.
Each employee who entered my Dads room would also tell my Dad that he would need to take off his two gold necklaces prior to surgery and they would offer to take them off him right then and send them to security for safe keeping. My father was very attached to each necklace (one from his mom and the other from his deceased wife, a nurse) and did not want them taken off, ever! It was agreed (by one nurse) that the necklaces would be taped to his leg during the surgery so that he’d always have them on him. This too, of course, was never communicated to other medical staff, and every time someone new walked into his room, they would kindly suggest that he would have to “take off those gold necklaces”, finally my Dad just freaked out!
I would watch his monitor above his bed: His blood pressure would rise, his pulse would rise… there were clinical implications to their poor team communication.
The two most important things to him were his good name and his gold necklaces and they couldn’t get either of these right.
Finally, now in surgery, as I am saying my final ‘goodbyes’, a nurse anesthetist came up and said, “Hi, Mr. Poore (not "Eddie"), I’m the nurse anesthetist. Do you know what I’m going to do?” My father replied, “Put me to sleep, I guess”. And she continued, “Yep, that’s right. And I see you have some gold necklaces on….” While she was still speaking, My father turned to me with a huge look of fear on his face and said, “Oh lord, they can’t even get these necklaces right, Jake!” That was almost the last thing he said on this earth.
My father died on the operating table that day. After his surgery the doctor didn’t even come out to talk to me. He sent one of his assistants out instead. When I asked what happened, we were told, “your Dad couldn’t hold his sutures, he was bleeding to death.” I asked if the blood thinner he was given the day before had anything to do with that, and she said, “Blood thinner, what blood thinner?” I couldn’t help but saying, “You guys didn’t even communicate the name he wanted to be called or stop asking him about his gold necklaces, maybe you didn’t communicate the blood thinner, either.”
Thanks for sharing this, Jake. Your story breaks my heart; maybe because my grandfather, who had a genuine fear of doctors, was named Eddie. How many other “Eddies” will it take?
I’m not certain that electronic medical records would have prevented what happened to Eddie or will prevent every medical error, but having access to all of a patient’s information at the point of care would prevent most of them. That, along with vastly improved caregiver communication and collaboration tools and better solutions to manage decision support, clinical workflow processes and quality would go a long way in improving patient safety. Paper kills. So does apathy and ineptitude. The time has come for an information technology revolution in healthcare.
Bill Crounse, MD Senior Director, Worldwide Health Microsoft
Eddie's story really touched me. I suspect at first we all will feel heartbroken like I did.
But why aren't we collectively angry! These types of stories shouldn't happen.
Where was the surgeon carrying out a pre-operation check ?
Where was the pre-operation check sheet started in the ward and continues with the patient to theatre ?
Where was teh nurse in charge of car for your father on that day ?
The issues here are system and people issues, it's great to be able to throw technology at a problem, but unless it's the right technology, it is not going to help solve these issues.
Healthcare is not a manufacturing process. There are variable inputs, variable processes along the way, with variable outputs at the end.
As soon as you start to try and treat it as such, that's when you will have problems.
Forget waht you know, and start at the beginning, but it's not an IT problem, it's a people problem you ahve which IT may contribute a role.
I would be the first to agree that what happened to "Eddie" could and should have been prevented without technology. However, having practiced medicine myself for many years I know how easy it is for things to fall through the cracks. Technology can help by giving providers all the information they need right at the point of care. Mistakes like this shouldn't happen, but they do; as do amputations of the wrong limbs, surgeries on the wrong patient, drugs administered in the wrong dose, etc.
Bill Crounse, MD
This tragic case was the result of multiple missteps, some of which may have been preventable by technology, and most of which could have been prevented with a little more human attention.
It sounds as if this unfortunate outcome was the result of potent anticoagulants being administered before cardiac surgery. But there are often other details, and thus this discussion is not about the specific cause of Eddie's death.
What this IS about is the question of whether technology and EMR can truly reduce medical errors and bad outcomes.
I am an avid proponent of EMR, and my own Family Medicine practice has been fully implemented on an EMR for four years.
But the truth is that EMRs, in their current iteration, seem to create at least as many opportunities for error as they prevent.
The errors, in the end, are still human. But software (which should be designed to reduce human error) often makes it easier for error to occur.
A layman might expect that conventional EMR software would have adequate clinical knowledge and error-checking to avoid prescribing the wrong drug or dose, but it turns out that these are EXTREMELY simple mistakes to make.
Imagine how easy it would be to click on "amoxapine" instead of "amoxacillin" when the two are adjacent in a long list of drug names.
Most EMRs aren't smart enough to know that amoxapine is a bad choice for treating an ear infection, and could lead to serious side effects at doses of 400mg three times aday.
This is a mistake that wouldn't likely be made by hand...
It's very easy to order a 500mg solution IV of Zithromax when the prescription should have read 500mg -tablets- orally...
Also: Drug interaction checks by the EMR can be so overcautious and repetitive that we tend to tune them out.
Every time I prescribe Micardis/HCT, the computer warns me that Micardis and HCTZ can interact to product hypotension... This is silly, and superfluous, and leads me to ignore my interactions warnings on many occasions.
The EMR doesn't make the mistake, but it seems to simplify the process of error.
Until EMRs are universally smart enough to prevent errors, I don't believe they should be publicized as such a crutch.
It's still the system, process, and people that need to be changed.
Eddie is a wonderful example of how poor communication can lead to bad outcomes. But paper did not kill him... People who didn't READ the paper killed him.
Thanks Aaron. And, I agree with you. IT isn't a panacea for preventing all medical errors, and as you say, the technology can itself introduce untoward events if it is poorly designed, badly implemented or goes unquestioned by the humans who rely on it.
Bill Crounse, MD
The use of technology on the doctor-patient consultation should be the process of educating and empowering patients and doctors. Doctors and patients will be more cooperation. It will allow them to engage in decision-making, and interpret and evaluate information with critical thinking.
I agree with Vince: "These types of stories shouldn't happen"
This is an example of poor communication practices - which could have happened despite the presence of IT systems.
However, there is no denying the fact that IT systems remove more opportunities for error than they introduce. More importantly, they enable easier data capture about the practice of medicine, which when analyzed by practioners has the potential to enhance the practice itself.
While healthcare is no manufacturing, it certainly can learn a lot about how analysis of data can result in new insights, new opportunities for efficiencies and better use of scarce resources.
Yep. My dad was in intensive care for three days with heart problems. Every single nurse around the clock for three days asked him if he was diabetic. He is not Diabetic and never has been diabetic.
I agree that this was a poorly designed process, and IT could probably have had a marginal impact. Its amazing that I had to go through a similar situation with my mother 22 years ago (in India when I was in Med school) and this type of issues still occur.
These are truly not considered errors because such hospitals simply don't make these incidents into workable examples for nursing staff. Poor quality professionals eventually prove very costly. It became clear to me a couple of years ago that it would only get worse because there weren't enough qualified nurses to go around, so the bar kept going lower. Quite often, I became a villain for stating the same to hospital administrators. After unsuccessfully trying to change such happenings, I have quit hospital work completely over the past 2 years.
I am not sure if IT can really fix this problem. Unless a medical professional considers his/her job as a profession and not simply a job, there is no quality/intensity. This is lacking in many nursing professionals nowadays. Everybody has to realize that providing high quality care requires high quality professionals, and these folks have to be compensated adequately. Unfortunately with all the current focus on cutting spending, I predict that things will get worse. I know its a stretch, but its imperative that we start valuing our professionals appropriately. I still cannot understand how a ball player is worth 14 million a year or a stock trader is worth a 100 million, when we cringe at paying a medical professional (who might be responsible for life vs death) adequately.
Wow, this story is heart wrenching. It's so important to know who is working on your loved ones. (not that you had any options at this point) Some doctors and their staff have no bedside manner at all, and that is sad.
I want to know that a doctor caring for my mom, knows who she is and that she is not alone. They need to know that the people who love her are going to make sure they care enough to ask a ton of questions...and call off things (if possible) if they are not completely comfortable.
I pray for everyone who goes into a hospital they they get the best care available....sadly enough that doesn't always happen. Jake I wish you the best in life. Be strong.
The information age of internet, ipods, and cellphones has both positive and negative implications for the health of the average family. On one hand, infinite access to entertainment in the home may discourage physical activity, leading to obesity and the litany of associated health problems. However, information technology can help families control their weight and make positive impacts on their own health. My family uses music to inspire our workout that we download from the internet and listen to on our ipods. I used to blame IT technology for my family's health issues, but now we're getting in shape together and its all thanks to the tools we found online. I'm using http://www.HighEnergyFitness.com to download workouts and keep my family moving! Obesity is the biggest drag on our healthcare system, and I hope more families find these tools and make use of them!