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Computer Error or Patient-Centered Care?

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually”  because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me.  She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?

As a physician, I am more informed than the average patient. As the retired Medical Director of the hospital where I was receiving the treatment, I knew and had good working relationships with my nurses and the pharmacist. As a physician seeking clarification about administration of their drug, I was accommodated and happily helped by the drug manufacturer. This process involved several discussions, local and long distance phone calls, sending of faxes, reviewing of minutes, and patience on the part of both providers and patient over several days; all for a rate of 4 1/2 rather than 6 hours for a just single medication. Was this negotiation worth it?

Don Berwick “uses his own wits to safeguard against errors” and now urges the adoption of patient-centered care to restore his dignity as a patient in the current medical world where “provider trumps patient” almost every time. (2) Negotiation between patient and provider from EQUAL bases seems to be the essence of patient-centered care.  The line between requesting and demanding can be a thin one. We successfully avoided defensive stances and threatening attitudes and never felt that we were engaged in a “disruptive shift in control and power.” (3) Is it reasonable to expect the average patient and the busy provider to conduct such successful negotiations most of the time? That is a tall order, but I hope that healthcare systems will be able to  support the process without bogging down the providers and frustrating the patients.

References:
1.  ”Patient centered care means meeting patient’s needs and preferences through shared informed decision-making which will reduce unneeded and unwanted services” – See Institute of Medicine, Institute for Healthcare Improvement, Robert Wood Johnson Foundation, The Commonwealth Fund, The Joint Commission, and Patient-Centered Outcomes Research Institute websites and publications.

2.  Remarks by Don Berwick before the plenary session of  the International Forum on Quality and Safety in Health Care, Berlin 2009    http://www.youtube.com/watch?v=SSauhroFTpk

3. “What ‘patient centered care’ should mean: Confessions of an extremist.” Don Berwick, Health Affairs 2009 Jul-Aug 28 (4)

Herbert Mathewson, MD, blogs at HUB’s LIST, a compilation of medical fun facts gleaned from a variety of medical journals, newspapers, other public and professional sources, and an occasional private communication.

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Michael Rawson
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Patient centered care can exist through patient and physician cooperation (or as it’s referred to in the article: negotiation), however it’s impossible to expect that most physicians would put up with hours of discussion regarding treatment before administering it. Unfortunately, the amount of people who need and seek treatment (with their own opinions about what is actually needed) are far too large, and for most physicians, time is stretched too thin. I think patient centered care can be achieved through providers who realize they are meant to guide a patient through their own care, versus making decisions on their behalf… Read more »