EHR Issue or Unmet Standard of Care?

Description

A patient with known antibiotic allergies received contraindicated medication prior to the procedure. Once discharged home, the patient developed a significant rash that required re-admission.

Key Lesson(s)

• Vulnerabilities exist with electronic health records (EHRs), including system design and how the user interacts with the system.
• While EHRs can assist in workflows, information may be available in multiple places and should be referenced when obtaining complete patient histories and developing plans of care.
• All clinicians have a duty to verify a patient’s allergies before ordering, approving, or administering medications.

Clinical sequence

A 70-year-old patient had a complex medical history with multiple allergies, including an allergy to an antibiotic. The patient also had end-stage renal disease and hypertension and was receiving dialysis three times per week via a right arm fistula, which had clotted. Thus, the patient was scheduled to undergo an operating room procedure for a new access site.

Pre-operatively, the nurse practitioner (NP) noted the antibiotic allergy in the “History & Physical/Pre-Op” note section of the patient’s EHR, but did not document this in the designated “Allergy” section. The night before surgery, the resident entered several orders into the computer, including the antibiotic to be given preoperatively, which was standard practice for this procedure. He did not enter a note into the patient’s record.

On the day of the procedure, the nurse in the pre-op area released the antibiotic order, and another nurse administered the medication. The anesthesia provider noticed the error and gave the patient IV Benadryl, noting no adverse reaction at that time. The surgery and anesthesia providers informed the patient of the error. Following discussions with these providers and with the patient’s consent, the decision was made to proceed, and the procedure was uneventful. The resident entered a post-procedure note indicating that no antibiotics were given before the procedure.

The patient was discharged home, where they began to develop a red, itchy rash on their trunk and extremities. They presented to a nearby hospital for evaluation and required admission for treatment.

Allegation

The patient alleged that a failure to reconcile their medication allergy resulted in them receiving a medication they are allergic to and requiring readmission for treatment of a severe rash.

Disposition

The case was settled in the medium range ($100,000–$499,999).

Clinical Analysis

• Reliance on a specific subsection of EHR for information
  The provider in this case reported he could not view the “Allergy” section in the patient’s chart. EHR systems typically house information in multiple places within a patient’s record, which can make it difficult to access information. Every effort should have been made to reconcile any allergies prior to ordering the antibiotic, including thoroughly reading the patient’s notes and communicating with the patient.
• Standard of care unmet by several clinicians
  Reconciling a patient’s allergies is a shared responsibility among many clinicians, including physicians, nurses, and pharmacists. Every institution should have clear policies for medication and allergy reconciliation, which providers should follow closely to avoid adverse events.
• Documentation issues
  The physician ordered the patient’s medications the night before the procedure, which may be viewed as a “time saver,” but could have contributed to the error if the clinician could not access all of the information. Additionally, in the post-op note, the physician wrote that the patient did not receive antibiotics preoperatively, which could be viewed as covering up a medication error.

Discussion Questions

• What is the process in your institution for reconciling a patient’s allergies?
• What are some of the main benefits and challenges for users when interfacing with EHR systems?
• Does your institution have a process for disclosing errors to a patient and family?