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Closed Case Abstract: Deaths Preventable with Computers

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Closed Case Abstract: Deaths Preventable with Computers

By Tom A. Augello, CRICO and Luke Sato, MD, CRICO

Related to: Ambulatory, Clinical Guidelines, Communication, Diagnosis, Documentation, Primary Care, Other Specialties, Surgery

Systems could have helped one doctor to consider colon cancer screening, and another doctor to follow-up on a referral.

Guest Commentators

  • Luke Sato, MD; CRICO/RMF; Cambridge, MA

Transcript

The following case abstracts are based on closed malpractice claims in the Harvard system. Some details have been changed to protect identities. Here's managing editor Tom Augello.

An analysis of malpractice data from the Harvard-affiliated institutions shows that, among cases that could be connected to health IT solutions, nearly 500 cases have risk management issues related to follow-through of tests or referrals and other hand-offs…and almost as many cases are related to decision-making issues, such as diagnostic errors or prescribing mistakes. In those cases, the average incurred losses ranged from $480-thousand to more than $800-thousand.

Dr. Luke Sato joins us now, to describe two cases and possible ramifications for Health IT. Dr. Sato is the Chief Medical Officer at CRICO/RMF, the patient safety and malpractice insurance company owned by the Harvard medical institutions.

Luke, we have two cases to talk about, and they were chosen to illustrate how health IT may help mitigate risks in the care process. Let's take them one at a time.

A.

Sure, if you look at, in general, our malpractice cases, two major categories of issues really start to emerge. One are cases that stem from decision making issues where individual clinicians' cognitive, knowledge, and judgment issues come into play. In other words, we need to see systems that help the providers make the right decisions. The second class of cases are cases where once the provider makes the right decision. We need to see systems that guarantee the providers actions are carried out and things don't fall through the cracks. This is what we call follow through issues. So, if you look at the two cases, the first case is a really a decision making case. It is a 60-year-old patient who was seen by her primary care physician for a physical exam. The physician noted in the record that the patient had a sigmoidoscopy, although it did not indicate where, why, or what the results were. And at this visit the rectal exam was negative for masses and the hemoccult test for blood in the stool was negative. The physician continued to see the patient over the next several years for episodic care as well as for routine physical exams. The documentation for this time period had no indication that the primary care physician discussed or ordered any colorectal screening tests.

So, four years later the patient experiences bloody stools and was sent for a colonoscopy, which revealed the mass. The patient was diagnosed with colorectal cancer with metastases. Despite surgery and chemotherapy the patient died a few years later. So, the issues here are clinical judgment. The patient didn't have an assessment to follow through. But the main issue is that the primary care physician really should have noted that the patient was above 60, and right now anybody above 50 is indication for having a colonoscopy screening. And so if the system provided a reminder or somehow knew that this patient was above 50, and led the physician to a colonoscopy, this would have probably mitigated this case.

Q.

And so we've seen IT systems that can help physicians with that?

A.

Yes, and I think the systems in our medical system right now to a large extent have come a long way regarding reminders and imbedding of these types of guidelines in their systems and they have become quite sophisticated over the last 10 years or so.

Q.

Let's look at the second case. So, that's going to be dealing with the issue of follow-up.

A.

Sure. This is a sad case. It is a 9-year-old boy who presented with a lump on his foot, which his pediatrician diagnosed as a callous. Now over the next three years the condition did not resolve despite continued concern that was expressed by his parents. When the boy was 12, the pediatrician referred him to a general surgeon for biopsy. Apparently there was an earlier referral to another general surgeon and this never resulted in any follow-up steps, and this case a clear cell sarcoma was diagnosed and the boy died at age 13.

Q.

Oh, that's a very sad case. When you think about health IT, what are we looking for that might prevent that kind of unfortunate outcome?

A.

So, as I said before the cases here are representative of a need of a system that enables the physician—that guarantees them—to follow through with actions that they carry out. So in this case, the case was appropriately referred to the general surgeon, but apparently it was never followed through. So in this case if we had a system that followed through once a physician made the right decision, then again this case probably would have been mitigated.

Q.

And so, we're looking for some sort of a tickler built in to an electronic medical record so that there would be no chance that a referral is made and that an assumption is made that the referral is followed up, that there were recommendations that came back and seen by the physician.

A.

That's absolutely correct. I think the systems currently that exist right now are extremely complicated. There is a lot of work flow that they try to also help, as well as improve upon. And in the future I think we could probably see systems that comb through the medical record and identify for the physician either abnormal test results or lab results and then serve that up to the physician. If that capability exists down the road I think none of these types of issues that you'll see will be coming through to us. The assumption here is that you have these reminders and tickler systems coming up to point the physician to the right … to make the right decision. Now the downside of this is that if the reminders and ticklers don't work, then obviously the physicians are becoming extremely reliant on this and therefore will not be able to make the right decision. So, down the road having the right reminders, having the right ticklers coming up at appropriate times in the context of the right patient is going to be extremely important and I think if that's not done correctly it could generate a whole new set of risks and problems down the road where we didn't even have experience before. So, I think the reliance on technology that the community is going to have is going to, I think, in itself is going to have some underlying risk to that.

Thank you. Dr. Luke Sato is Chief Medical Officer at CRICO/RMF. For Resource, I'm Tom Augello.


January 1, 2008
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