An Extremely Teachable Moment

John Mandrola MDIt was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection.

It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction.

Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug interaction occurred because of alert fatigue—or distraction.

I am a cardiologist; I am also a patient. I want the Duncan case to be a turning point, a wake up call, a never event that serves as a spark to improve the delivery of medical care. Right now, all that this case has changed are tweaks to EHR protocols and checklists. We need more than tweaks; we need big changes.

An uncomfortable truth is that medical mistakes are normal. Errors, like this one in Texas, have occurred since doctors started treating patients. The good news is that technology has made medical care better. No credible person suggests a return to the paper-chart era. Yet, it is still our duty to face mistakes, learn from them, and in so doing, improve future care. Being honest about root causes is necessary.

Another truth about medical mistakes is the ensuing rush to inoculate against blame–which always comes. In the Duncan case, initial blame was assigned to the electronic health record. The computer software failed to flag the travel history in the physician “workflow.” (Just using the word, workflow, hints of the bureaucracy problem.) And you know there is trouble when hospital administrators use the passive voice. “Protocols were followed by both the physician and the nurse…”

Then came blame for the doctor. Physicians are tough on one another. This case was no different. A chorus of physician voices quickly condemned the error. How clear things look in hindsight, and, especially, to health policy gurus, who likely haven’t laid hands on a feverish patient in years—if ever.

The real lesson of this mistake, though, is bigger than EHR or human error. Blaming a computer or a doctor misses the root cause. Errors like this occur because the minds of caregivers are unsettled and agitated. Attention is deflected away from basic things, like the history, physical findings and simple verbal communication between nurse and doctor: “Hey doc, this guy with fever was just in West Africa.”

The distraction issue is complicated. It’s more than just the inane electronic records, which have morphed into invoices rather than useful narratives. It’s more than the shift mentality of the younger generation. It’s also the chronic burnout and sinking morale of caregivers. You can’t extract joy from a beautiful job and expect human beings to deliver care like robots. Distrust is toxic. Caregivers are now as fearful of fraud allegations in their documentation or low productivity as they are of making a medical error.

Infectious disease scares people, but the spread of caregiver distraction is worse. Nearly all of us will need medical care some day. When we do, we will receive it from another human.

I urge you; do not be fooled again. Politicians and policy makers once told us there were billions of dollars to be saved in increased scrutiny for billing fraud. And yes, there is fraud, but the threats and audits spread distrust and fear. Now we have pages of distracting CYA documents and unsettled minds. We were told that electronic records would transform medicine—as if they were Apple products. Now we have doctors and nurses wrestling with dropdown menus instead of diagnoses and treatments. We were told protocols and timeouts and checklists would make healthcare as easy to run as a restaurant. It was magic then; it’s still magic now.

What frustrates me most about this crisis in patient safety is the complacency and tolerance of nonsense. Everyone in healthcare knows how dangerous it’s becoming to deliver even basic care. And yet it’s ignored, or accepted, as if it has to be this way. Ebola is nothing compared with the systemic distraction of caregivers.

To turn the Duncan error into a force of good, citizens (future and current patients) must help reformers do some simple things. First, it’s time to stop any new reform that forces a doctor or nurse to take their attention away from their patient. The litmus test should be: does this help the caregiver help the patient? Second, people on the ground level of healthcare, those of us with our hands on people, need more power to make necessary changes. Third, EHR companies need an incentive to design products that help not obfuscate care delivery.

Take care of the people who will care for you. Bureaucracy is doing the opposite right now. This needs to stop. Lives, maybe yours, depend on the mind and well being of that man or women you meet in the emergency room or operating room or clinic.

5 replies »

  1. Fascinating how a post like this generates no real thread response, because the gist of it is about doing responsible patient care, and my take is one of two things results from the basic reader population here:

    not many doctors who really care about patient care either read here or read the post, or, it did not attack EMR with the ferociousness that other posts have done since the story hit.

    But, I am not surprised. And this will just replicate itself, as does the virus.

    As does our leaders.

  2. Totally agreed, Timely and proper care of patient can save their life. And doctors and nurses should understand it instead of caring about bureaucracy.

  3. “First, it’s time to stop any new reform that forces a doctor or nurse to take their attention away from their patient.”

    Like, well, looking away from the pt and scribbling illegibly in a paper chart?

  4. Excellent post Dr. Mandrola. My wife and I are both physicians and were just discussing this. Part of being a physician includes that ability to listen to that “still small voice” in the back of your head to lead you when something doesn’t look right. In today’s world, especially a fast paced, busy ER situation, it becomes harder and harder to do that. You are also expected as a healthcare worker to make sure you have punched all the right computer buttons so the hospital can get paid and get the requisite bonus or avoid penalties. This means less real patient care. The point about taking physicians and nurses away from their primary function is key.
    I sincerely hope someone is listening.