Page 34 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

CASE STUDY

A 53-year-old male patient of a multi-specialty physician

practice with documented “no known drug allergies
(NKDA)” was seen for pneumonia. He was prescribed

a quinolone antibiotic and subsequently experienced a
seizure. The next day, the physician determined the seizure

was caused by an allergic reaction to the medication. The
physician immediately documented the allergy in the EHR.

With that action, the EHR updated all of the patient’s past
records with the new allergy, completely overriding the

“NKDA”. The printed records from visits years earlier printed
the quinolone allergy. However, the “screen view” seen by

EHR users showed quinolone allergy (updated 2/20/18).
A medical malpractice lawsuit was filed, and the plaintiff’s

counsel obtains the printed record, indicating the allergy
was known for years. The case against

the physician was ultimately dismissed,
but only after months of investigation and

headache.

There are many instances of systems failures related to

electronic health records. The challenge is to determine if the

failure is with a component of the EHR or with the internal policy
for users. In either case, the responsibility for vetting the issue
and correcting it lies with the physician. Although customizing

features with the EHR vendor can be costly, workarounds can

lead to the failure of the clinical decision support functions and
lead to patient harm.

Page 34