I think you're referring to this: https://www.wired.com/2015/03/how-technology-led-a-hospital-to-give-a-patient-38-times-his-dosage/ It's a fascinating example of the swiss cheese effect, and should be required…
Curbside Consult with Dr. Jayne 9/28/20
Just when you can’t think 2020 can get any weirder, here comes the story of a copperhead snake that made an appearance during a patient’s televisit.
Every week it seems like there’s something more bizarre going on than there was in the previous week, and that’s really saying something when you’re in the 39th week of the year.
I’ve had another couple of surreal clinical shifts, to the point where I can’t even talk about them. Some of the issues are just medically complex and are nearly impossible to blind for HIPAA purposes. Others have been so traumatic for the care team that I don’t want to relive them in any way, shape, or form.
In that context, I was glad to have a low-key informatics weekend. I spent a good part of it being on call for an upgrade, playing the role of the “IT person who just happens to be a physician.” They wanted someone to be on call to do additional testing of any clinical issues that cropped up during the upgrade, as well as to test any hotfixes that had to be done on the fly.
Fortunately, my client is a solid organization that understands the value of a well-planned upgrade. They’ve been tweaking and enhancing their test scripts over the years to the point where they are super solid. We only had one small issue that turned up early Saturday morning, and fortunately, it was with a new feature that we just turned off while waiting to troubleshoot with the vendor on Monday morning. It was certainly different from the white-knuckled adventures that I had with my IT team in my early days as a CMIO.
The rest of the weekend was spent on various consulting projects. One was to help a startup company with their messaging, which I always find to be fun work. Sometimes the smart folks behind a great tech idea don’t fully understand how to translate their solution into the language their target audience is looking for. I did some proofing for a redesigned web site and editing of a potential case study. The most fun part of the messaging work was working with a couple of sales reps to help them hone the delivery of their pitches. Sometimes being able to correctly pronounce medical words is the difference between building credibility and being shown the door, so I hope I made a difference in how those individuals will be able to convey their message going forward.
Another project involved designing order sets for a mid-sized medical group, which has spent a lot of time trying to do the work without much success. The physicians struggle to agree on anything, and the IT team is trying to distill hundreds of different physician-specific order sets down to something manageable. The project was originated by the quality department, who was tired of trying to promote various quality interventions when physicians would just refuse to use the global set and use their own instead.
Essentially, I had to export all the order sets and compare them by specialty and by location, identifying the commonalities and analyzing data about their use. The physicians had agreed to get on board with a data-driven approach. When I’m done, we’ll have a real understanding of which order sets are used and which parts of order sets are manually altered. They actually allocated ample time to mine the data and achieve physician buy-in, so I’m fairly confident the project will be successful when it goes live in a couple of months.
I also started working on a new medico-legal project, which was at times exciting, but overall made me sad. If there’s anyone in a healthcare IT organization who believes they can take actions within an EHR and not get caught, they really should think twice. Sifting through hundreds of pages of audit trails isn’t what I enjoy doing on a beautiful fall day, but it’s important to my client to understand the havoc that their employee created. I’ve identified the impacted patients (which fortunately isn’t that extensive of a list) and the next step is to audit the individual charts to see whether the employee modified any of the data, and if so, what they modified. I also need to see what kinds of data was specifically visible and whether any of it falls into the sensitive category.
Stories like this are a good reminder for organizations to check their security settings and to make sure employees only have the minimum access necessary to complete their work. It’s not just “a HIPAA thing,” but it’s a major integrity issue when you have to notify patients that someone was caught snooping through their charts.
I’m getting things caught up and organized since I’ll be out of office for part of next week, this time taking a much-needed mental health break. From a clinical standpoint, I know there are a lot of us that have hit the breaking point and I can tell I’m approaching mine if I’m not already there. It’s time for three days in the desert to sort things out while trying not to think of COVID (although I’m sure it will be front of mind on the flights there and also on the way home).
My favorite desert escape is closed through at least 2021, so we’ll have to see whether VRBO can deliver. Regardless of the accommodations, I’m looking forward to lots of sun and fresh air with no mosquitoes or ticks involved. My traveling companion already sent a list of the cocktail supplies she’ll be bringing with her, so it’s looking to be a good getaway even if we have to shake our own martinis since we’re physicians who will be self-isolating. I’ve packed three good books to get me across the time zones and back with some reading material in the middle. One is serious, one is a book club pick, and one is the pure unadulterated madness that only comes from Carl Hiaasen.
What strategies have you used to refresh and recharge during 2020? Leave a comment or email me.
Email Dr. Jayne.
Just got back from an almost week-long camping trip. No laptop and barely a glance at my phone except to see how late I slept in each morning (hard to do with a rooster crowing nearby!). There’s nothing like spending hours sitting next to a babbling brook staring at a crackling fire to take your mind to pleasant places – or no place at all. Enjoy your trip!