Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Monday Morning Update 10/14/13
From Alarm Fatigue: “Re: patient death. Alarms on hospital doors are ignored.” San Francisco General Hospital (CA) offers no explanation of how a 57-year-old patient reported missing from her hospital bed was found dead 17 days later in an alarm-equipped hospital stairwell. The hospital’s chief medical officer suggests that alert fatigue from “a cacaphony of chirps and beeps” may have contributed to the problem.
From Patient Advocate: “Re: retina surgeon follow-up appointment. My two drugs had a dosage change, given to me verbally. I started second guessing myself as I was sent upstairs to see my specialist, who reviewed the surgeon’s notes send by fax with different dosage instructions. The meds seemed to be pre-printed on the form, so I asked the tech to check with the surgeon. The specialist then added another drug, giving me a sample with no dosage label and verbal instructions. Most of this specialist’s patients are 50 an over, going home with verbal instructions only. How about a simple printout of dosage instructions? As I was leaving the exam room, the person charting on the laptop asked me about my other eye drugs so she could enter data. Guess she was seeing the trees and I was walking through the forest … with less than perfect vision.” Technology should get neither the blame nor the credit for how providers interact with their patients. They are responsible for choosing and using whatever tools they need to get the job done. I can’t think of any other professionals who blame the computer for their inability to perform at a reasonable level, although I also can’t think of any professionals whose minute-by-minute behavior is managed by government, insurance companies, and unseen owners using the computer as a blunt instrument of control.
From The PACS Designer: “Re: 5th Gen iPad. Now that we have the news that October 22 is the launch for the 5th Gen slimmer iPad-mini, here’s an advanced look courtesy of the Sonny Dickson website. The smaller form factor is destined to be a hot item, and eagerly sought by those who are constantly attached to their device.”
The reader-requested poll about ICD-10 and liability and workers comp insurers yielded a scattershot of inconclusive responses. New poll to your right: what’s the cause of Healthcare.gov insurance marketplace technical problems?
Here’s John Lynn’s latest Hangout, recorded live at CHIME 13.
In Northern Ireland, medical imaging technology firm Cirdan Ultra acquires the assets of GE Healthcare’s Centricity Laboratory Division and will take over support for the former Triple-G product, which was at one time the highest-rated LIS (before GE acquired it, obviously).
ESD wins the Best Video Award at the CHIME CIO Fall Forum with a CIO-customized Diamond Dave-style version of “Just a Gigolo.”
Weird News Andy concludes that “this just doesn’t cut it.” A man in China suffering from arterial embolism saws off his own leg after being turned down by a doctor because he didn’t have enough money to pay for the procedure. He jammed a block of wood in his mouth and cut the leg off with a saw, also losing three teeth from biting down hard in pain. The man appealed for help to have the other leg amputated, resulting in a doctor offering his services for free.
The non-profit New Cities Foundation publishes a video describing its urban e-health project in Rio de Janeiro, in which GE Healthcare provided “e-health backpacks” to allow home visits for health maintenance in an urban environment.
For the geeks among us looking for a new technical toy, check out WearScript for Google Glass, which allows programmers to control and develop for Google Glass using Javascript. The developers hope to create an open ecosystem around Glass and to encourage accessibility.
Berlin will host the first HIMSS European mHealth Summit in May 2014.
The sold-out eClinicalWorks user conference started this weekend at JW Marriott Hill Country in San Antonio, TX.
On tap this week: Cleveland Clinic’s 2013 Medical Innovation Summit a the just-opened Global Center for Health Innovation in Cleveland. I’m surprised any healthcare work gets done at all in October given the number of people that seem to do nothing all month except attend conferences.
Crain’s Chicago Business names the board of Merge Healthcare as having the least-competent Chicago-area board of directors given their pay, noting that the company lost $28.8 million last year while the six-member board took home $8.2 million in compensation.
Vince launches his HIS-tory of McKesson, having tapped into the personal memories of several industry pioneers including Walt Huff himself (the “H” in HBO & Company). Vince also got some reader help in identifying some of the HIT faces of yesteryear. Vince spends a lot of time gathering information that you won’t find anywhere else, and I for one enjoy the heck out of every episode.
Contacts
Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.
More news: HIStalk Practice, HIStalk Connect.
Hi Vince – is G Neilson Buchannan, the former CEO of El Camino Hospital in MIS pioneering days? If so, he’s retired and going strong in Los Altos CA.
Any comments on the “go live” of Obamacare Marketplace? Glad that I did not have anything to do with that roll-out. Can you imagine rolling out an EHR | CPOE with those kinds of “glitches.” OMG.
#deathinthestairwell
This is eerily similar to the death on the rooftop in Pittsburgh in 2008. http://www.highbeam.com/doc/1P2-19587305.html
Are there any others?
In Pittsburgh at the time, they said that they “never want it to happen again”, but it appears as though there were few lessons learned that were applied to the rest of the hospitals in the country.
At UCSF, they said they were checking on the patient every fifteen minutes while she was on a med surg floor. That is hard to believe.
They too in San Fran never want this to happen again.
Although “alarm fatigue” may have contributed to this San Fran General death, the intense focus of the doctors and nurses poring over their computer terminals charting in complex hard to use grids and searching for data, while using CPOE, may have distracted them from the care and observation of the patients and what was going on on the patient care unit.
Will this count as an HIT asociated death?
Has anyone heard of such a gruesome hospital death prior to any hospital being wired?
Thank you for your attention to this matter.
@Patient Advocate (Retina Surgery Follow-up) == Med Rec – one of the most critical elements of the patients journey and one of the most socially and technically complex functions in the EMR and work system design.
Look at all the potential touchpoints for a safety event:
“dosage change, given to me verbally”
“second guessing myself”
“sent by fax with different dosage instructions”
“meds seemed to be pre-printed”
“asked the tech to check with the surgeon”
“sample with no dosage label and verbal instructions”
“asked me about my other eye drugs so she could enter data”
The interaction included five people,each with different view of reality. They all thought they had the patient as the focus of their attention.
The patient
The retina surgeon
The specialist
The technician
A scribe
I extend my condolences to the family of the woman, Ms. Spalding, who died alone in the stairwell of a hospital in San Francisco. Obviously a never event, it belies an infrastructure dysfunction that enables the swiss cheese model to have too many holes.
As long as hospital staff are distracted by chirps, buzzers, bells, and electronic grids and idiosynchratic electronic ordering, the risk for patient neglect will increase.
RE:PAtient Advocate…Understand that most states require any medications given to a patient by a physician, even samples, have the same labeling required of a pharmacy…for these exact reasons…As stated this has no0thing to do with technology ( as it has been an issue way before computers),,,meerly a medical profesional not doing their job
The story about the 57-year-old patient who was missing for 17 days (before being found dead) is quite alarming. Presumably the police were notified? I’d be interested to hear what sort of search the police did.