Texas Health Presbyterian Hospital in Dallas has offered differing accounts of what went wrong on September 25, the day their Emergency Department mistakenly sent the nation’s first Ebola patient back into the community instead of admitting him.  Over the next four days, that error put at risk for Ebola many of the individuals who came into contact with Thomas Eric Duncan. Delays in transmission of important clinical data can lead to delays in diagnosis.  In Mr. Duncan’s case, such a delay could have allowed the disease to progress from not receiving the appropriate treatment.  Thorough diagnosis and effective treatment increasingly depends on robust healthcare data communication.

 

The hospital’s two explanations, first blaming a “work flow” issue in its Electronic Health Record (EHR), and then denying the same issue, are not necessarily contradictory. (A) EHR’s can be configured to store nurse’s and physician’s notes separately, without any interface between the two.  If there were no interface, then there was arguably no  “defect” in the EHR nurse – doctor workflow.  Although the EHR was functioning as configured, one might still ask why the nursing staff did not notify the ER physicians that a patient from Liberia had just presented with a fever, a presentation highly suspicious for Ebola.  To paraphrase Cool Hand Luke, what we had here was a failure to communicate. (B) This may also explain why Texas Health Presbyterian reportedly has a higher re-admission rate than other hospitals in Texas.
Communicating important data is an increasing challenge in healthcare (C).  How big a problem?  In an investigation published in 2011, my colleagues and I learned that “failure to communicate” had been an increasing factor in medical malpractice lawsuits for the prior 20 years.  By the time of our investigation, malpractice awards paid for cases that included communications failure totaled about $4.8 billion annually in the US.  The problem was that the number of test results to communicate keeps increasing, while healthcare providers were under increasing pressure to spend less time on each patient.  Data we evaluated from Harvard’s Risk Management Foundation indicated that gaps most often arose in communications to patients, followed by physicians.

 

The leading US hospital-accrediting agency, The Joint Commission, emphasizes rapid communication of medical data, designating it National Patient Safety Goal #2.  Consequently, to maintain accreditation, it is incumbent on hospitals to manage healthcare providers’ communications performance.

 

The Duncan case illustrates that with healthcare communication, there is more at stake than hospital accreditation.   Robust communication is vital for the welfare of patients, and increasingly, the public.

 

Brian Gale, MD

Managing Member, SaferMD, LLC

Dr. Gale is a radiologist and the founder of SaferMD, LLC, a healthcare safety auditing organization.

References

A-  Manny Fernandez et. al.  Dallas Hospital Alters Account, Raising Questions on Ebola Case.  New York Times.  A1.  10/3/2014.

B – Cool Hand Luke.   Warner Brothers/Seven Arts (1967)

C – Gale B, Siegel D. Davidson S and Juran D.  . Failure to communicate reportable test results:  Significance in medical malpractice.  Journal of the American College of  Radiology 2011;8:776-779.  Selected as JACR CME Activity of the Month.