In a previous post I briefly discussed how communication failures in the transmission of test results are common. Many people think that widespread use of electronic medical records systems throughout all of our health systems will improve medical care.
You cannot improve a physician’s standard of practice simply by altering the means by which records are kept and transmitted. In fact, many communication errors are institutionalized. For example, one of our clients visited a University medical center for the purpose of evaluating his spinal fracture that seemed to have occurred in the absence of any trauma. An appropriate array of imaging studies and laboratory tests were ordered. At this medical center, the electronic medical records system was designed to assume that any lab report issued on the date of the patient’s discharge was reported to the patient’s floor before the patient was discharged. Though a report of results issued after 12:01 a.m. the day following discharge was regularly made to each ordering and attending physician as a matter of policy, any results issued after discharge but before midnight were reported to no one except the medical records.
A two-year delay in the diagnosis of cancer and an associated death sentence for our client was the basis for a lawsuit being filed. We knew a lab report existed indicating the need for prompt follow-up and that such follow-up would have diagnosed the cancer more than two years earlier with the expected benefits of an earlier diagnosis. We didn’t know why it happened. Through intensive investigation we uncovered the flaw in the electronic medical records system and brought this system delay flaw to the hospital’s attention. The flaw had been present since the system’s inception years earlier. This is but one of many similar cases we have handled where, as a result of defective policies or procedures, catastrophic injuries have occurred.