Jeffrey Carlisle: More Harm than Good?

December 5, 2013

Healthcare IT, Patient Safety

When you need critical care, you would hope to go to a hospital with the very latest monitors and electronic medical record (EMR) system, right?

Be careful what you wish for.

Could it be possible that these technological marvels cause more harm than good? Consider the following:

  • Nurses and doctors each spend an extraordinary amount of time “interacting” with a computer system.
  • Monitors at the bedside and at nurse work stations show a lot of data, but not all of the relevant information for the patient.

Information gaps are wide, but not apparent.

These information gaps cause real harm to patients, such as the recent and needless death of a dear friend in the prime of her life.

After receiving state-of-the-art medical care following a boating accident, she lost her life in an ocean of data that lacked cohesion, integration, and continuity as she drifted from one caregiver to the next. Voluminous data generated provided an illusion of management.

Physicians treating a patient need far more information than what is displayed on a monitor, yet much of the data on the monitor is not providing any new information. For example, monitoring SpO2 while the patient is receiving supplemental O2 could provide a false sense of security.

If information from monitors is incomplete and in need of better context, then it is EMR to the rescue!

Why do caregivers spend so many hours engaged with the EMR?

A. They are receiving vast amounts of useful information.

or

B. User interfaces are so weak that users spend minutes to do tasks that used to take seconds.

I choose B.

So, the net result of the well-equipped hospital may be to overload the caregivers with data which distracts them from paying attention to the patient. The precious time at the bedside is distracted by the monitors, IV pumps, etc. Specifically for my friend:

1. Nothing in the EMR highlighted that the hospital had accidentally created a hole between her airway and esophagus, so attempts to ventilate caused more harm than good.

2. Monitors showed that her respiratory values were OK, but the values were wrong and incomplete.

3. They were unaware that she was a nurse, so they dismissed her pleas as “anxiety” and sedated her.

4. Monitors and EMR required so much attention that no one took the time to look at her expanding belly to see air fighting her lungs.

Her heart stopped.

During resuscitation, clinicians were forced to actually pay attention to the patient. They determined the reason for her arrest, relieved air pressure they had created in her abdomen, and her heart resumed beating normally. But it was too late; her brain had been damaged beyond recovery, and she died a few weeks later.

Monitor/ EMR robbed her of a thoughtful integration of information that could have saved her life. A slower pace and 3×5 cards would have served her better.

 Jeffrey Carlisle is an entrepreneur in the field of medical devices and systems. He and his family live in New Hampshire where he operates Leveraged Developments LLC and OurHealthConnector LLC.

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3 Comments on “Jeffrey Carlisle: More Harm than Good?”

  1. Suzanne Steidl Says:

    Thank you so much for this, Jeffrey. I’m so sorry for your loss and the unnecessary suffering that your friend, her family and her friends endured. I am ever fearful of hospitalizations and yours is just another example of why it’s so. What a shame.

    Reply

  2. John Abbott Says:

    Anecdotal cases like this one are always heartbreaking, but whether it was due to poor technology integration, improper training or simply operator error is something a more thorough investigation will have to determine. My guess is that it is more of a user error and training issue than a technology one. As much as some manufacturers try to make the use of modern technology “idiot proof,” such devices are still complicated technological marvels that require at least some training and practice. Too many organizations today view training as an optional expense that can be cut without consequence when time comes to tighten the financial belt. Sadly, they end up paying for it many time over later on when such cases as described above occur. Sadly, they often fail to link the failure to lack of training such that the same things happen over and over.

    Reply

    • Anonymous Says:

      In the recent FDA guidelines for infusion pumps, they have taken away the manufacturer’s opportunity to rely on “training and documentation” as a mitigation for errors. Why? 40 years of evidence that has not been effective.
      This blog was intended to be anecdotal, not scientific. The best result of it would be to provoke half a dozen quantitative studies to show the magnitude and root cause of the problems.

      Reply

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