Four emergency department (ED) physicians at Rhode Island Hospital in Providence recently received subpoenas in connection with tests they had mistakenly ordered, according to Politico. This report raises disturbing questions about whether physicians can safely report their errors, even if those mistakes result from the design of their electronic health records (EHR) system, observers say.
Politico reports that the physicians received the subpoenas after ordering scans on the wrong sides of three patients and for one wrong patient. Upon discovering their errors, which may have been due to EHR system issues, they reported them. Clinicians are legally required to report wrong-site and wrong-patient issues to the Rhode Island Department of Health (DOH), department spokesman Joseph Wendelken told Medscape Medical News.
Wendelken said that DOH itself did not serve any subpoenas on ED physicians at Rhode Island Hospital. “However, that doesn’t mean that investigations are not underway,” he noted. Asked about Politico‘s allegation that DOH plans to hold a hearing on the physicians‘ actions, he said, “I cannot comment on active investigations. However, hearings are sometimes a part of the investigatory process.”
In a statement provided to Medscape Medical News, Wendelken said that DOH is legally required to conduct investigations when hospitals fail to identify patients accurately or conduct wrong-site procedures. “These investigations are done by impartial professional boards that thoroughly review all of the relevant facts and make decisions that are in the interest of the public’s health and safety,” he stated.
The physicians who allegedly received the subpoenas for the improper scans have not been identified. Politico quoted one of their colleagues as saying that the subpoena charged that the physicians‘ errors constituted “incompetent, negligent, or willful misconduct” and that the tests were “medically unnecessary.”
Rhode Island Hospital has been under a state consent decree since last June, according to the Providence Journal, because of three mistakenly ordered radiological tests and a procedure performed on the wrong section of a patient’s spine. To avoid regulatory action, the hospital pledged to spend at least $1 million to implement system improvement measures.
Most states require hospitals to notify their health departments about “sentinel” safety events such as a death or loss of limb that resulted from a medical error, said Lorraine B. Possanza, DPM, program director of the Partnership for Health IT Patient Safety at the ECRI Institute in Plymouth Meeting, Pennsylvania. However, she told Medscape Medical News, it’s not clear that ordering a wrong-side or a wrong-person scan rises to the level of a sentinel event if it didn’t cause patient harm.
Nevertheless, Wendelken said, the state requires all wrong-site procedures and identification events to be reported to the health department “because a healthcare professional ‘order’ starts a series of events that may involve medication, a lab test, a diagnostic test, or an invasive procedure. Patients in Rhode Island need to be confident that when they enter a licensed facility, every medication, lab test, diagnostic study, or procedure was intended for them. Our patients expect and deserve safe and reliable care.”
Is It the EHR’s fault?
Peter Basch, MD, senior director, IT quality and safety and national health IT policy, for MedStar Health, a Washington, DC-area health system, told Medscape Medical News that he was appalled by the report about the Rhode Island subpoenas. In essence, he noted, the reported subpoena accused the doctors of medical misconduct for incidents that might have resulted from the complexity of their EHR and that might have been corrected before being carried out.
“When you report a near-miss, will the department of health’s reaction be, ‘gotcha?’ ” he said. “Are we going to penalize you for misconduct because of a mis-click?”
Gita Pensa, MD, an ED physician at Rhode Island Hospital and Newport Hospital, said in a tweet that “the disclosure of errors is necessary to improve patient safety…Physicians have been willingly self-reporting near misses or errors, often but not always related to EHR entry, to the DOH. And instead of working with those docs to target pain points, the DOH has begun individually targeting those MDs with threats of fines and threats of loss of licensure, and databank reporting…I am worried about what this will do to the rates of actual error disclosure, and I am also quite sure this will not do anything to actually help foster a culture of safety.”
Similarly, Possanza said that it’s “very dangerous” to punish doctors who report safety issues, including incidents that result from the design of an EHR. “You want to report it and you want people to bring those issues to light,” she said.
Physicians can and do make mistakes in EHRs in a number of different ways, she noted. It may be in the ordering process, the imaging process, the transfer of the image to the EHR, or how a report was dictated, she pointed out.
If clinicians believe that they could be penalized for reporting safety issues, Basch said, they’ll be less likely to report them. “The benefit of reporting those issues would be system improvement, but the penalty would be that somebody’s watching you and you might get a subpoena for almost making an error. It’s the wrong thing to do.
“The overall purpose of patient safety initiatives is not to protect doctors, it’s to protect patients…We do not help patients by creating a culture of fear among doctors who are trying to do their best.”
Possanza said that it was terrible that the Rhode Island doctors’ licenses might be in jeopardy over these incidents. “Your license is your life. Losing your license or having it restricted impacts every aspect of a physician’s life.”
Rhode Island Hospital spokesman David Levesque said in a statement, “Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our health care environment, including the processes our caregivers and staff follow. Furthermore, the hospital‘s culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tireless work in providing world-class health care.”