Hospitals present a host of operational challenges. Patients arrive with a variety of ailments and the mix of work changes by the day or even by the hour. Resources are always limited and time can be of the essence. This is especially true in the emergency room. Sure there are challenges up in, say, the obstetrics ward, but they can at least keep non-obstetric cases out of the ward. The ER, however, has to take all comers and decisions have to be made quickly. Perhaps, then it is not surprising that ERs are a major source of malpractice suits (Hospitals Overhaul ERs to Reduce Mistakes, May 10, Wall Street Journal).
Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims. The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.
Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.
Here’s a the article’s author discusses some of her finding and how hospitals are trying to reduce the number of errors.
This is an interesting challenge. Some slices of healthcare have fallen in love with checklists — protocols to step through to make sure that nothing is forgotten. That works great when a set of resources is consistently processing similar patients. Yes, every heart surgery patient is different but consistently verifying the purpose of the surgery, making sure all the necessary supplies are in the OR etc can prevent mistakes down the road. ERs are somewhat different because the variety of cases is wider and more variable. Further, perfect data may not be available when it is really needed.
While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren’t available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University.
Gaps can include a missing medical history, no record of abnormal vital signs such as blood pressure or heart rate, a lack of timely access to radiology or lab reports, or information lost in a shift change. Crico’s analyses show poor doctor-nurse communication at critical times often causes mistakes.
So what can managers do to make ERs run more smoothly? The article discusses a number of things different hospitals are trying. Many of these aim to make sure that all caregivers have the same information. That may mean that a doctor and nurse do triage together so that they have a common understanding of the patient’s ailments. Or it may mean having “triggers” on certain vital statistics. If any of these get out of whack, patients are given priority in moving through the queue. Or it may mean encouraging caregivers to “huddle” to exchange information face-to-face. That brings us to the most interesting quote of the article.
At Taylor Hospital in Ridley Park, Pa., where 30,000 emergency patients are treated annually, emergency chief Gregory Cuculino says maintaining electronic medical records has had an unexpected downside: Staffers type information into the system but don’t verbally communicate with each other. “Huddles allow everyone to go over the case, so if someone says, ‘Mrs. Smith in room four looks good,’ the nurse has a chance to say, ‘She just threw up again,’ ” says Dr. Cuculino.
This highlights a particular challenge of medicine: There is some information that isn’t easily codified or cannot be transcribed fast enough. Electronic medical records may over the long haul give a more complete patient history that is more portable than physical records. However, they may not be the easiest way to convey fast changing information in the dynamic environment of an ER.