Everyone suffers.  We’ve all had tragedy in one form or another.  Sometimes the tragedy is huge and noteworthy, and everyone is talking about it.  My “tragedy”  was quiet.  Very few people even knew I had a “situation.”  It was my choice to keep it to myself and that’s okay because it was the kind of thing that evolved over a few years, and I was sick of listening to myself. Even the people who loved me and knew the details were tired of it.   As I was going through this I tried to do all the right things:  I ate right and got plenty of rest, I exercised everyday, I went to church and prayed for endurance.  I talked to a kind and knowledgeable professional.  I eliminated all stress that I could and I leaned on my parents, my best friend, and my beloved uncle for strength.  I did the best I could and when that wasn’t enough I did some more.

Recently I had an experience that made me remember that difficult time.  The pain felt brand new but familiar. It was unwelcome, but helped me realize what I didn’t do during that time  was advocate for myself within a complex medical system.   I did not  (could not??) do for myself what I did on a regular basis for my patients.   I’ve been thinking about this a lot over the past day.  Nurses are advocates.  We hold our patients (sometimes literally) in the palms of our hands.   I know what the chain of command is and I’m not afraid to use it.  As nurses (and maybe as mothers, wives, and daughters) it’s common to put others’  needs before our own.  (I will apologize here for using a gender bias  but men still only comprise about 7% of the registered nurses in the USA.)  We go to work sick so we don’t leave our units short staffed, we stay late to chart, we skip meals to make sure our patients eat their own, and we’re late to our own family events to comfort a stranger’s family member.  As a professional group we need to advocate for ourselves with the same energy we do for our patients.  We need to advocate for each other and be kind to one another.  This will make us better nurses (not to mention healthier nurses) and our profession deserves this.

I did not have the happy ending I was planning on, which stunned me.  Right up to that point, I was pretty sure the universe had my best interests at heart.  If I had done things differently ten years ago it may or may not have changed my outcome.  It doesn’t really matter, but as I reflect on that time, the only thing I regret is that I didn’t insist on trying a different approach.  I won’t make that mistake again.  It took me a long time to change directions and create a life that makes me happy.  I would like to say thank you to the people in my life who came along for the ride.

Most EMR’s offer a series of templates that are customizable by the organization, whether it be a hospital, an office practice, or a clinic.  The templates are often specialty specific.  For example, a pediatrician’s product is going to include things like immunizations and growth charts but the cardiologists’s product is going to have other information critical to that area of medicine.  The important thing to keep in mind is that you want to be able to customize your product to suit your needs.  This is no small task, especially if your EMR is going to be used across a network of practice areas.

After our hospital administrators had chosen a vendor, we convened a group of clinicians from all six of the hospitals in our network. We had representation from all disciplines from all the hospitals.  The process began by having the vendor demonstrate the product to our large group.  This actually took quite a while, because as you might imagine, there was resistance and a lot of “It’ll never work” type of reaction. 

After we learned enough about the product to know what needed to be adapted for our organization we got to work on the customization process.  Our goal was to standardize the EMR for all six sites.  I’m an employee of Hospital A but theoretically, I should be able to walk into hospital B, C, or D and be able to document my patient care without skipping a beat.  In the end we had to compromise on several areas.  For example, on the nurse’s status board, which is an overview of the patient assignment, one can see the patient’s name, room number, date of birth, allergies, etc.  After the basics, there are sections that can be customized–do we want to see the patient’s  height/weight on the status board, the date of the last BM, the next time blood work is due, etc.  It was truly amazing to learn what was so important to each individual nurse.  It was quite a challenge to meet the needs of nurses across six hospitals, especially since some of the facilities are small community hospitals and others were large teaching institutions. Other areas of customization are found on the actual documentation screens.  For example, on our cardiovascular screen we have additional assessments that allow us to  document on procedure specific data, like cardiac catheterization or a pacemaker assessment.  Not all of the sites need these screens, so these menus are collapsible and only need to be accessed as necessary by the end-user. 

A 2006 study by the Department of Family and Preventative Medicine, University of South Carolina, found that institutions that had a  comprehensive EMR saw improved care and  a reduction in medication errors.  These improvements were found only among the facilities that had the ability to alter and customize their EMR and had a sysem that included decision support tools and reminders.  Other studies have found that it’s not so much the use of the EMR but rather the functionality of the EMR that makes the difference.  Dagraso, D. et al, in their article “Implementation of an Obstetrics EMR Module: Overcoming User Dissatisfaction” point out that trying implement a cumbersome EMR product that does not meet the end-user’s needs or meet his work-flow requirements will not be successful.  It can be safely assumed that documentation will be incomplete if it does not support the end-user.  We’ve all heard “if it wasn’t documented, it wasn’t done” since we began our careers. EMR vendors must be challenged to provide a product that enhances our practice rather than dictates it.  EMR users must insist on a package that is customizable, safe for the patient, and provides a way to document the patient’s story in a fluid fashion.  Unfortunately, I don’t think we’re there yet.

The Patient Protection and Affordable Care Act (PPACA), also known as “Obamacare” has become law.  Whether you agree with it or not is your business.  My business as a clinically active nurse and as a Legal Nurse Consultant (LNC) is to try to understand it and how it will affect my practice and the work of my attorney clients.  One piece of this legislation involves the mandate that all patients’ medical records be electronic by the year 2015 (this date keeps changing–it used to be 2012, then 2014, now 2015).  An enormous amount of money has been set aside to help health care organizations make the transition from paper medical records to electronic medical records (EMR) or electronic health records (EHR).

Let’s assume we’re talking about a hospital.  “Good Hospital”  uses the money appropriately, selects a vendor and a product, and initiates the conversion to electronic documentation.  This is exactly the point where medical malpractice issues may begin.  According to Ronald B. Sterling, CPA, MBA, and author of Keys to EMR Success (Greenbranch Publishing; Phoenix,Maryland; second edition, 2010), “Every aspect of EHR selection, implementation, and use may be examined in the course of medical malpractice discovery to uncover the source of the incident, or undermine the records that are being presented in defense of the malpractice claim.  Anything could be a malpractice issue, from the product itself, the way it was set up, or how you’ve been using it.”

A 2010 report by Conning Research and Consulting found that the increased use of the EMR will drive up the cost of medical liability insurance.  The researchers believe that documentation errors and software flaws will lead to a rise in medical liability claims.  In 2009 $36 billion dollars was provided by the ARRA stimulus legislation for Health Information Technology.  This understandably encouraged many software companies to develop their own version of the EMR.  There are more than 700 vendors selling EMR products in the US.  As of October 2011, there were 499 ONC (Office of the National Coordinator for Health IT) certified products.  This certification is very basic. CCHIT (Certification Committee for Health Information Technology) also certifies these products.  It’s estimated that only 10% of the available EMR products would pass this more strenuous certification.  Bear in mind that the certification is voluntary at this point, and there is no regulatory agency that monitors the software for quality control.

You would think that a design flaw would be the responsibility of the vendor and clinicians would not be held liable for any error that occurred as a result of the product.  However, most vendors’ contracts basically say that they do not practice medicine and it’s up to the clinician to be sure the product is being used correctly.  In addition, there are gag clauses, which prohibit the vendor’s clients from publicizing information about software flaws that may cause patient error.  The irony of this is that part of the ARRA HIT (health information technology) legislation was to improve patient care!  A poor EMR product may lead “Good Hospital” to a corporate negligence claim, as ”Good Hospital” has a responsibility to provide a safe place for patient care and a responsibility to choose a vendor that provides a reliable EMR. 

Health care organizations should discuss with their liability carriers the potential risks of conversion to the EMR and develop protocols to reduce that risk.  Vendors need to commit to a product that meets clinical, legal, and record management needs while protecting the patient.  Finally, clinicians need to demand functionality that enhances their practice and makes quality patient care the priority.

I recently came across an article about a nurse who committed suicide after making a medication error that killed a baby at Seattle Children’s Hospital in 2011. (Suicide After Medical Error Highlights Importance of Support for Clinicians, Rebecca Hendren for HealthLeaders Media, May 10, 2011)

Reading the story of Kimberly Hiatt, RN and the baby who died, Kaia Zautner, made my blood run cold. This type of accident could happen to any nurse during any shift. When I was a new nurse I made a medication error that kept my patient in the hospital for two extra days. I missed a Coumadin order. This blood thinning medication is used with other anticoagulants to keep the patient safe from blood clots. I will never forget the patient who was gracious in accepting my apology. I will also never forget how horrible it felt to realize that my mistake could have hurt my patient. It changed my practice.

The process of administering medications is routine, but it’s complex. The steps that are involved including reading the physician’s order, making sure the order is transcribed correctly, pulling the medication from the dispensing machine, bringing the medications to the patient’s room, verifying the patient, verifying the medications, thinking about the medication and why the patient is receiving it, and finally giving the medication. It sounds simple enough, but during any given medication administration, these other things can and do happen:

• I am interrupted in the medication room by a doctor asking a question
• I am interrupted to take a phone call from Radiology
• I am interrupted to respond to a patient alarm
• I am interrupted to take care of another patient’s chest pain
• I am interrupted to speak to a family member waiting for me at the nurses’ station
• I am interrupted to move a patient from his bed to the stretcher to go for a test
• I am interrupted to help a patient go to the bathroom

You get the idea and if you are a nurse, you feel my pain! If you are a patient, you should be concerned that the medication administration process is not protected. In 1981 the aviation industry implemented “The Sterile Cockpit Rule.” This came about after the FAA reviewed a series of accidents that were caused by flight crews who were distracted from their flying duties during critical phases of the flight (www.airlinesafety.com). If medication administration is a “critical phase” of my day’s work, then it makes sense that I not be distracted during that time.

The problem is that as nurses we feel like we have to be all things to all people all the time! Unless it’s a true emergency, I should tell the doctor who is interrupting me, “I’m sorry, this is not a good time. I will find you when I’m done.” Maybe we need “Do Not Disturb” signs on the med room doors. Some hospitals have tried an orange vest that the RN wears during meds that alerts other staff to not interrupt. That activity reduced medication errors by 47% at a California hospital (www.nursezone.com). I don’t think I want to wear an orange vest, but I would like to have my activities respected.

Safety starts with strong leadership. Hospital administration needs to provide ongoing education to all hospital staff, including physicians, regarding the seriousness of medication delivery. Nurses need to feel empowered to discourage interruptions and advocate for both their patients and themselves. We can promote patient safety through our own actions. If I make a lethal medication error, the distraction is not going to be held accountable for the tragedy–I am. The distraction is not going to have a hard time sleeping–I am. The distraction is not going to apologize to the patient or his family–I am.

Enough said.