Whoa -- the hospital retracted. The doctors system *did* have travel info on Duncan!

[magical thyme]

"But on Friday evening, the hospital effectively retracted that portion of its statement, saying that “there was no flaw” in its electronic health records system. The hospital said “the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow.”

http://www.nytimes.com/2014/10/04/us/containing-ebola-cdc-troops-west-africa.html

[arthritisR_US]

1. It's Texas, why the feck am I not surprised...nt

[narnian60]

4. This could have happened anywhere.

[morningfog]

11. Not true. Other cities would have been careful, serious

and diligent. It could have happened many other places, but not "anywhere."

[840high]

16. Of course.

[mucifer]

2. Yeah, but it's always a great idea to blame the nurse.

[Erich Bloodaxe BSN]

3. Translation - the doc didn't check that part of the notes.

I don't like it, but it's actually understandable on 'case 1'. You can bet a lot more doctors will be looking a lot more carefully for such going forward, at least while things are 'hot'.

[FarPoint]

5. I mentioned on Wednesday here in a thread...

That the computerized charting is a huge barrier to effective communication of a patients assessment....The computer guided the nurse through pages of required blanks to fill which takes one off the 1:1 assessment of the clinical picture presented by the patient. The program essentially controls the assessment..it is distracting. Secondly, reading the computer chart is also boring, bland and time consuming.

[magical thyme]

6. personally, I think Ida Briggs nailed it

and I also think that, other than the dozens of cases where people have been monitored that have until now all ended up negative for Ebola, there are probably just as many if not more that have slipped through the cracks and just happened to have not had Ebola.

There had to be a first; Dallas drew the short straw.

I don't know that it is "boring" to read a chart. Certainly when you are working a long shift, have to little time to spend with each patient, too many blanks to fill in, it is easy to miss a critical piece of information or not make a link between two pieces of information.

Severe signs and symptoms immediately draw a kind of attention and focus that mild symptoms do not.

[FarPoint]

8. I agree, Ida nailed it.

Depending on the computerized charting has its negatives. Nurses, physicians, they all must first employ the 1:1 assessment skill with the patient. The computer is only a tool, like a BP cuff is a tool. Yes, this patient, Mr. Duncan has exposed some major flaws and will no doubt evoke clinical assessment changes for the better.

[Mariana]

7. I guess when they realized they opened themselves up

to having hundreds or thousands of other patients descending upon them, asking if their treatment had been fucked up by this "flaw", they decided to back off this bullshit excuse.

I'm sick to death of the "news" outlets reporting rumours, speculation, and outright lies.

[alcibiades_mystery]

10. More likely the software company called bullshit and forced them to retract

Or they realized that hundreds of other hospitals have the same system, and their admins and workers were like WTF? For real?

[magical thyme]

14. or the in-house person/people who customized the system for their specific in-house needs said

"yes it is, right here," pointing at it.

And the hospital looked and saw "whoops, yes it is right there," in the middle of 50 other lines of text, all in small print/small font and easily missed.

But I think Ida Briggs nailed it.

[Barack_America]

23. Travel history is the responsibility of the physician to ask.

Regardless of what this hospital says. Taking a complete social history is hammered into medical students and residents.

[merrily]

35. Yep. I had a rash they could not diagnose and they asked my

family where I had traveled. (I was unconscious.) It was only that I have hypersensitive skin, but they didn't know that. However, I guess the patient was not forthcoming about his exposure, either.

[Barack_America]

22. Don't mess with EPIC.

It's considered the gold standard of electronic records.

[magical thyme]

30. we're supposed to be switching to EPIC where I work

it's been postponed a couple times. Some people in the lab were sent on EPIC training last year, but not all of us. I've never seen it.

[Windy]

9. computerized chart

As the chart is computerized they should be able to program an automatic flag/alert in place when a history of travel to west Africa and symptom presentation of fever, vomiting etc are charted.

[freeplessinseattle]

13. Exactly! How hard can that be to find some competent techie to add such a vital feature?

Seems like common sense.

[kestrel91316]

26. Exactly. Have the system hooked up to WHO reports of whatever deadly diseases you want,

make sure all locations are kept up to date, and when X symptoms coincide with X country with X disease, bring on the bells and flashing red text.

I'm a cat vet and even I could probably figure out an algorithm to do that.

[freeplessinseattle]

36. Heck, my own cats could do a better job, they're so darn smart!:)

Not much escapes their attention!

Seriously, though, what a bizarre fail with something so important. Hope other hospitals are taking heed!

[Beaverhausen]

31. What about the human who heard him say he was in Liberia

Once she heard that she should have stopped everything and taken measures to get him quarantined. Supposedly they had a drill about this. Who cares if the records are correct once someone with a disease like this presents himself.

[librechik]

12. I get it

when I worked at St. Jos, some of the doctors were dependent on others to do the computer thing for them. It's probably not as bad now as 16 years ago, but I can understand a doctor not pouring over every detail of a computer screen. Besides they're busy and speed read.

However, it points out the fact that medical errors are rampant and those are going to kill and endanger us until the system is changed.

[exboyfil]

15. I would like to know the patient workload

for the doctor who made the decision to prescribe antibiotics and send the patient on his way

[840high]

17. I would like to know his

level of medical experience.

[exboyfil]

18. I would be guessing but

I bet the doctor is in residency.

[Barack_America]

24. Residents can't discharge patients without attendings at least laying eyes on them.

The encounter can't be billed for otherwise.

[kestrel91316]

27. I'd like to know if he/she even knows where Liberia is or that there is an Ebola epidemic there.

[Barack_America]

25. In most ED's an NP or PA would see a patient such as this.

But, eventually, the attending physician would have to sign off on the assessment and plan.

[TriplD]

19. Do we know that there wasn't a seperate workflow for uninsured?

I'd like to see how patients insurance factored into the decision to send him home with a handful of pills.

[magical thyme]

20. I don't believe the doctor's and nurse's charts show insurance information

information flow is based on "need to know." So patient registration would collect that information and that would flow to billing. The doctor or nurse have no need to know that I'm aware of. Maybe some DU doctors and nurses could chime in here to confirm.

In the lab, I don't see any insurance or payment information. I can see the patient's name and DOB, medical record #, diagnosis and I can see the lab tests ordered, the results, the normal ranges for each test, the ordering physician. On the labels I can see their location (eg, ED vs ICU).

But the test result information that I see is formatted differently and somewhat different from what the doctors see. For example, a few weeks ago I replaced an instrument CBC differential with my manual diff based on my results. The doctor came down a while later looking for absolute counts because, for some reason, when we use the manual diff it doesn't send the absolute counts to the doctors and this particular doctor wanted to know the absolutes.
I could see the absolutes in my system; he couldn't in his.

[TriplD]

21. I have some experience with computerized workflows

It wouldn't be hard to configure a system to flag an uninsured patient for some sort of fast-track treatment without providing the doctors that specific detail. If his insured status factored into the lack of treatment then it could be really easy prove if it was programed into their workflow system.

I think their excuse was a half-truth and it was workflow related. Just not the way they said

[magical thyme]

34. Triage doesn't work that way.

Incoming to ED are triaged by who is critical and who can wait. It is that simple.

I know that the doctors and nurses I work with are very dedicated and hardworking. I know that back in the lab, we run our asses off. We aren't looking to see if somebody is insured before we run tests and report their lab results. We're looking to see if results are critical and calling them to the doctor as soon as they're confirmed. If a chest pain comes in the door, we're running to make sure their troponin is reported asap. If we're on break and we hear or see commotion in the lab, we drop our fork and run back into the lab to see if they need help. I've had doctors with critically ill patients run to the lab from the ED to get their results straight off the instrument.

What you are claiming is really, really insulting.

Someday when you or somebody you care about is having a heart attack or bleeding out or having a extreme reaction to chemo, you will be grateful for that.

We don't know if the triage nurse isolated the patient or how their ED is set up. The doctor should have noted the patient's travel history and put 2 & 2 together, but didn't. The patient should have made clear he'd had direct exposure to Ebola and didn't.

If people with mild flu-like symptoms or other mild symptoms are moved out quickly, it is because they don't normally belong in the ER and if it is flu or a cold they are contagious to other patients around them. And if it's busy, somebody who just walked in the door may need the bed. Just 2 weeks ago, the biggest hospital in our state had patients stacked in the aisles and 27 people in line waiting to get in. There was not an ED bed available in the state and they had to ship people to Boston just to get into an ED.

The mistake likely was because they simply are used to working in one way and are now having to reverse some priorities. Somebody with mild flu-like symptoms must have travel history closely questioned and potentially isolated.

A poverty-bigoted doctor or nurse wouldn't have the ability to modify the system. Very few people would have the ability. And believe it or not, hospitals are inspected repeatedly by various nonprofits and government associations. That includes looking at their records and who has accessed what information. That kind of situation -- systematically targeting uninsured for dumping -- would not be hidden and I'm guessing would not be legal.

[merrily]

28. So, they lied at first? Not unusual.

[CullenBohannon]

32. ouch

[uppityperson]

33. "There had to be a first; Dallas drew the short straw. " As you put it elsewhere.

Mistakes happen. I am glad that this was as small as it was, though indeed bad enough. I hope with the wide publicity this has received that other places are more aware now to prevent it from happening again.