Ebola: the communication mishap had to do with information system setup. very informative article.

[magical thyme]

It burned my butt that first some DUers were blaming the nurse, and then blaming the doctor. It was, as I suspected from the outset, a stupid system/process issue that separated the information the nurse entered from the information the doctor received.

Also, the reason they put a security guard there is because the idiot quarantined family let a kid go to school against orders.

And last night they found an appropriate crew to clean the apartment.


http://www.usatoday.com/story/news/nation/2014/10/03/crew-cleans-ebola-patients-familys-apartment/16633211/

Crew cleans Dallas apartment of Ebola patient's family

County officials say they had trouble finding a cleaning crew willing to sanitize the residence, but late Thursday night, a crew was seen entering the apartment.

"We've used them in HIV/AIDS situations where we needed to do a cleanup and other blood-borne illness cleanup," said Dallas County Judge Clay Jenkins. "They use appropriate disinfectants, and are appropriately licensed to do that."


"According to the release, the nurse asked Duncan if he had traveled out of the U.S. in the past four weeks, and he told that nurse he had been in Africa. The nurse entered that information into the nursing portion of Duncan's electronic medical record. However, the hospital found in their investigation of the incident that there was a flaw in the way the physician and nursing portions of their electronic health records interacted.

In their electronic records, physician and nursing workflows were kept separate, and the documentation of travel history was located only in the nursing workflow portion of the records. Since the flaw was discovered, the travel history documentation was relocated to a portion of the records that appears in both workflows, and has also been modified to specifically reference Ebola-endemic regions in Africa, hospital spokesman Wendell Watson said.

[valerief]

1. So the person responsible for hospital workflow system fucked up? Who tested this?

Who approved this?

The hospital fucked up. Period.

[magical thyme]

4. the information flow. everybody is fed the information differently, depending on their job

and somehow, somebody didn't realize or missed that doctor's need travel history.

[dixiegrrrrl]

12. The day before, teh hospital had held a drill on Ebola procedures.

Says the news.
Guess intake notes were not recognized as a problem or used in the drill.

[pnwmom]

2. They found an appropriate clean-up crew but that crew was turned away because

it didn't have the appropriate transit permit allowing it to transport hazardous waste on Texas highways.

You'd think this specialized crew would have known about the need for such a permit . . .

Anyway, no word yet on how long it will take to process the permit.

[GusBob]

3. The problem with EHR's

They are always trying to reinvent the wheel or build a better mousetrap it seems. the systems are always tweeked and updated such that you get used to it one way and it gets changed.

on top of that, the government keeps changing their rules for meaningful use and attestment that in order to follow the regulations you are clicking and toggling so many templates that human interaction and communication are often neglected. Information gets lost ESPECIALLY in the patient history

we had an austic savant kid in our clinic, he counted 217 mouse clicks for his encounter ( not key strokes).

sometimes feels as if your chasing your tail and details get lost when you are busy dotting "i's" and crossing "t's"

[Daemonaquila]

5. It's more than a process issue.

It illustrates that systems are set up to capture information for CYA, but not to actually inform people who need the info. It goes right back to the idea that in "work faster, make us money" hospital settings, they don't want staff to "waste time" by reading "more than they need to." It's even possible that harried docs contributed to the problem by complaining that they need core info, not a whole lot of "extraneous" data to sort through. Hey, no problem - they'll go for "efficiency" every time.

[alcibiades_mystery]

6. So it wasn't a nurse or doctor, but admin and programmers

Oooooof!

[Beaverhausen]

7. I think the minute he told her that he had been in Afrca, she should have him put in quarantine.

The procedure should be changed. Fuck getting his info and records. Make people safe, damn it!

[HereSince1628]

24. The hospital in Dallas is now part of an historic case, and their story is of mistakes

The textbooks love to do case histories with mistakes. They teach strong lessons.

I don't believe any other institution in the US wants to show up as a mistake in a case study that will be studied for decades.

Consequently, I believe you'd find that hospitals all over North America have already looked at changes in their procedures.

Hearing what patients say is almost certainly part of it.

[Beaverhausen]

25. well I certainly hope so

it's nuts. She should have stopped typing and started the procedure that they PRACTICED a few days before.

[Whiskeytide]

8. Regardless of how the omission occurred...

... it was still a monumental screw-up by the triage nurse. And I think it is disingenuous for her to try and blame the electronic system. She took the information. Unless she had been living under a rock, she had to have known the implications of flu-like symptoms in a patient who had recently traveled to West Africa. She should have hit the "Oh Shit" button immediately. And if they had been working with this system for even a short period of time, you can't tell me that they - the ER staff - had not figured out that the system was not getting the information from pt A to pt B.

Maybe she was genuinely uninformed and untrained, and had not watched the news or read the newspaper or looked at a website in weeks - I guess that's possible. But damn. This was a pretty significant moment - and she just dropped the ball. I feel badly about how badly she must feel about what happened - but I can't give her a pass on this.

This sounds more like a hospital's risk management department looking to include a third party (the system designers/installers) in the liability equation.

[MohRokTah]

9. So the IT staff failed to adequately unit test the software before going live.

Something like that should have been picked up in unit testing.

[ljm2002]

14. This was a design flaw...

...so testing of any kind was unlikely to show a problem. In-depth reviews might have, had someone thought of this scenario -- which they apparently did not.

Our best and most reliable protection is for humans to use their judgment in light of the situation at hand. Unfortunately, the nurse was probably unaware that the patient's travel information would not show up for the doctor.

As is often the case, it isn't that easy to assign blame. It is hard to foresee all scenarios, and complex systems have many possible points of failure.

[RobinA]

22. I Work

in a medical situation, and I can tell you that "humans using their best judgment" is in no way part of the equation, whether records are electronic or handwritten.

[herding cats]

10. Just days before the hospital had a drill for possible Ebola cases.

How was this not noticed then? This hospital was supposed to be trained to handle Ebola cases. This is not a facility which claimed to not be prepared before the man walked in the door.

Also, the claim his "overall clinical presentation" of fever and abdominal pain in a person who had just traveled here from West Africa wasn't an implication he had Ebola by the vice president for the hospital system Dr. Mark Lester, begs the question of what is an implication? Since this patient had Ebola, and his symptoms and travel history weren't enough to have him put into isolation upon their being know by the first level of screening staff, what is the requirements?

Lastly, the fact that they're saying if he'd told them he'd been in contact with a person who had Ebola they'd have dealt with it differently is eyebrow raising. Well, what about hypothetical person who travels here from West Africa who was in contact with a symptomatic Ebola person, but never realized it and contracted the disease? How are they going to know to isolate that patient?

This is a learning moment. We need to accept that mistakes were made and that they need to be addressed and dealt with in a professional manner. Then we need to make sure these mistakes are not made in the future. To try and lay all the blame on an error in the software system isn't being factual, and it's not all that needs to be corrected there.

[Barack_America]

11. Somehow, physicians and nurses were able to treat patients before "workflows"...

...and computers. It was called asking a question and remembering the answer.

[MH1]

17. Well, there's this thing call "cost cutting" that's been going on.

For awhile now.

[tblue37]

28. Plus all the busy work involved in satisfying the requirements of

a compliance regime.

[Mariana]

18. Yeah, funny how no one ever noticed this "flaw" before

the ONE GUY with Ebola walked in.

Makes you wonder how many other patients have had their treatment fucked up because of this. I think everyone who's been through there recently should be asking whether their doctors had all the information they needed.

[suffragette]

29. Excellent point Mariana

Who knows how many other patients were affected by incomplete info.

[Mariana]

33. It's enough to make me wonder if this story is even true.

If it is, they should be made to review the record of every patient that was seen there since the system was put into place. They need to make sure all of them were treated appropriately in spite of the doctors not having access to potentially important information.

[mainer]

13. Don't nurses and doctors talk to each other?

In ERs I've worked in, a nurse would just go to the doc and say, "Hey, we've got a patient who flew in from Liberia and he has a fever." Now all this information has to go through some information flow worksheet?

[Texasgal]

20. Not anymore.

Electronic records were supposed to help with pt. flow.

[eppur_se_muova]

15. But but but computers make everything more efficient !

They're labor-saving devices ! Really !

Don't look at me like that.

[ecstatic]

16. If the nurse took down that information, s/he had an obligation to verbally warn the staff.

I can only think of 4 reasons why s/he didn't verbally warn the staff, and only one is acceptable:

1) The nurse lives under a rock and didn't understand the significance of what the patient revealed. UNACCEPTABLE

2) The nurse fully understood the implications but kept silent because it wasn't her problem: Let the rest of the staff figure it out (perhaps after direct contact). UNACCEPTABLE

3) The nurse is absent minded: Well versed in the Ebola outbreak, but so distracted that she heard the information but didn't process it as she was entering it in the system. UNACCEPTABLE

4) The nurse entered the information, but before she could alert the staff, she fell sick, freaked out, or had an accident and had to be hospitalized herself, so she was unable to relay any further info that day. ACCEPTABLE

[FormerOstrich]

19. The infamous

computer glitch!

Glitches transfer votes to republicans, prevents critical information from being disseminated, and many many other things!

Honestly, I think a lot of the blame comes to rest with the patient. If I thought I had ebola, no matter how remote the chance, I would be standing there, with gloves and mask, saying EBOLA......I MIGHT HAVE EBOLA...OMG stay away from me.....don't touch me...stay away....HEY DOC........I MIGHT HAVE EBOLA!!!!

I would not let them send me away. I would think my only chance would be for them to treat me immediately not later.

[uppityperson]

21. The kid went to school "despite doctors' recommendations." And quit calling them idiots, seriously.

If you want to call someone an idiot, make it whomever quarantined them within an infectious apartment for the last couple days. Quarantining them in a such a place meant continued exposure to the virus and increasing their chances of getting sick themselves.


Thank you for the article, but please stop using insults. The article says it was a "recommendation", not an "order". It could be they did not understand, in which case put the blame on the person instructing them for not making sure it was clear.

[cwydro]

23. Yeah, I agree.

Idiot is a bit strong. Obviously the CDC mishandled this from the get-go, so who knows what they told the family.

Plus, English is not their first language. Misunderstandings could easily happen.

If there are idiots...pretty sure it's the bureaucrats that screwed this up from the beginning.

[Mariana]

34. It's easier for misunderstandings to happen

if officials refuse to use clear language. If they're using words like "request" and "recommend" when they mean "order", then of course they're going to be misunderstood.

[riverwalker]

26. It was the EPIC Software

that nurses have been struggling with and complaining about for years. Hospitals paid billions for it, the design was by people who had no idea what nurses actually do. We spend more time nursing the software than nursing patients. More time at keyboards then the bedside. It takes more time to document a task then it does to actually do it. As a old nurse, I spend twice as much time charting now on EPIC than when we used pen and paper. It's a mess.

Epic Systems feeling heat over interoperability

http://www.modernhealthcare.com/article/20141001/NEWS/310019945

Epic Systems rapped for not sharing records

http://host.madison.com/ct/news/local/writers/mike_ivey/epic-systems-rapped-for-not-sharing-records/article_86d8a74c-48e2-11e4-863b-b3683789be28.html

[riverwalker]

27. here is where it says they used EPIC in Dallas

It felt like aha!
I knew it was EPIC.

http://www.bloomberg.com/news/2014-10-03/electronic-record-gap-allowed-ebola-man-to-leave-hospital.html

While Watson didn’t respond to questions about why that happened, he said the software, made by Epic Systems Corp., has been reconfigured to bring patients’ travel history to the physician’s screen. It has also been modified “to specifically reference Ebola-endemic regions in Africa,” the hospital said in a statement today.

[Barack_America]

35. Well, then, fuck that. I know for a fact EPIC's standard H&P for physicians...

...includes a full social history, including travel history. Unless this Texas hospital had that removed from theirs, which would be ridiculous because it would bump you to a lower reimbursement level.

Bottom line, any physician who takes a history for a chief complaint of fever and does not ask a travel history, has not done a complete history. I get how busy physicians are, but I cannot condone such vital parts of how a physician comes to a diagnosis to be turfed off to nurses. We need more time with our patients, not better "work flows".

That is, if he even saw a physician, which we don't know he did.

[kestrel91316]

31. What an apt name for it. As in: EPIC FAIL.

[kestrel91316]

30. I'm more than a bit peeved that the physicians just didn't happen to notice for HOW MANY

MONTHS OR YEARS that their ER patients didn't have any travel history.

Seriously???? They just didn't notice an important part of history was missing - that was being harped on repeatedly in CDC communications to the medical community??

Simply appalling.

And the maroon who approved that defective computer software needs to be frogmarched.

[LisaL]

32. And they just had a drill on how to handle Ebola.

Apparently even then they didn't notice that a very important information was missing.
Boggles the mind.

[Barack_America]

36. Pretty sure it would be fraud for questions a nurse asked...

...to be documented in the physician's encounter note. Reimbursement is dependent on the completeness of the physician's interview.

[rainbow4321]

37. Hmmmm....the doc still had a responsibility to directly ask

If the guy had recently travelled. It is part of the history and physical done by providers. Especially with stomach problems and fevers. You ask stuff like what have you eaten lately, have you travelled outside the country recently, etc...

I just hope the crappy electronic software problems makes headlines like "blame the nurse" did!!