News Feature | November 19, 2013

Misuse Of EHRs Blamed For Deaths

Source: Health IT Outcomes
Katie Wike

By Katie Wike, contributing writer

Deaths at a VA hospital have been attributed to poor use of the EHR system by hospital staff

AirForceTimes reported last month, “Three more patients have died in a Veterans Affairs Medical Center as a result of negligence - the latest in a series of preventable deaths that have occurred at VA facilities nationwide. An internal VA investigation ... found that three patients died last year after receiving inadequate or improper care at the Memphis VA Medical Center emergency room, including one who had a fatal reaction to a medication that he was known to be allergic to.”

The three deaths at the Memphis VA Medical Center led to an investigation by the Department of Veterans Affairs Office of Inspector General (OIG) that concludes, “We substantiated that a patient was administered a medication in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately five hours after presenting to the ED.

“We found that the facility took actions as required by VHA in response to the unexpected patient deaths, but noted that implementation of action plans developed through RCAs was delayed and incomplete. We found inadequate monitoring capabilities for patients in some ED rooms, an issue identified during our site visit last year.  We also found that nursing ED-specific competency assessments had not been completed.”

Government Health IT interprets the OIG report, writing the deaths “could probably have been prevented with better communication, documentation, and layout design” and the OIG “largely substantiated the claims, finding physicians missing nurse notes and EHR alerts, and a poor ED design leaving some patients only partly monitored.”

 “One patient came to the ER complaining of back and neck pain and confirmed an aspirin allergy with a nurse upon arrival, but the physician reviewing the patient three hours later hand-wrote on paper an order for the aspirin-containing anti-inflammatory drug ketorolac, missing an alert that would have noted a contraindication and bypassing the medical center’s policy of digital documentation,” the report stated.

Another patient came in complaining of back pain and the EHR alert that could have saved her life either never went off or was ignored. S/he slipped into a coma after receiving a combination of narcotics, tranquilizers and sedatives and died 13 days later.

Nurses using the EHR record were not properly checking previous notes either; one patient was documented as confused and disoriented and then later categorized as alert by another nurse.

Another problem was the layout and design of the emergency department. “We found that the physical layout of the ED does not allow for adequate monitoring of all patients,” wrote the OIG’s team leader on the Memphis report, Karen McGoff-Yost. “Since there is no central monitoring system for some rooms, alarms from monitoring equipment in these rooms might not be heard.”

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