Missed Information and Lost Limbs
The challenge of how to computerize medical records in the United States is a sensitive issue, and the form that these records will take is a matter of concern to every individual.
Consider the case of an 82-year-old man who underwent successful coronary artery bypass grafting at his local hospital. Several days post-op, when he complained of coolness and color changes in his hands and feet, he was seen by the attending cardiologists and then by a consultant in vascular surgery.
A careful review of his blood tests would have suggested an uncommon but well-known complication of the blood thinner Heparin that causes abnormal clotting in blood vessels. The worst thing a doctor can do in that situation is to order more Heparin, but that is precisely what was done. The outcome for this unfortunate patient was a series of amputations.
It may be tempting to conclude that the failure to carefully review the lab tests was an obvious breakdown in protocol—the fault of the medical team—but this would be a retrospective analysis. Lawyers representing hospitals will remind juries that “Hindsight is truly 20/20.” The only fair way to assess negligence is to apply a prospective review of the patient’s medical chart. The form of a medical chart, and the ways in which it presents or omits information, has a profound influence on the decisions that follow. In this case, when the patient’s chart is presented chronologically in the form of serial data, the flawed decision-making process is self-evident.
Although a medical chart may not be available to practitioners in an electronic format because the hospital’s software may be inadequate, the chart will certainly be the centerpiece of any trial that follows a catastrophic outcome.
—Excerpted from Wrench in the System: What’s sabotaging your business software and how you can release the power to innovate by Harold Hambrose (John Wiley & Sons, Inc., New York). Order your copy of this book.
