New Epic Tab

Dr. K asked me if I was using the new category in Epic, our electronic charting system.  I answered blankly that I did not know anything about it.  Sometimes I appear remarkably foolish because I tend to delete everything in my personal in basket, often without reading the more bureaucratic type messages.  It sometimes comes back to haunt me.

It turns out that Dr. K's center is piloting this new category, and if I recall, it is on the left hand side of the screen and says "Send Incident Reports".  Incident reports are an anathema to nurses because they usually involve medication dispensing errors or patient accidents.  As much as lay people would like to believe that these are covered up, they are actually churned out regularly, and done mostly by the people who committed the error.  All health specialties have this reporting system.

Medical errors are mostly system errors where one small mistake snowballs its way down the line through other professionals, ultimately ending in harm to the consumer.

Incorrect dosage written by physician--->transcribed by unit coordinator--->signed by nurse--->

sent to pharmacy unrevised--->wrong dose, wrong med, wrong person at the end of the line. This is the most simplistic of scenarios actually and much has been done to find and correct mistakes along these channels.  The pharmacy where I work frequently calls us to ask about dosages, but also to often ask about drug substitution for something less expensive.  This has made us less than happy to confer with them.  Allergies, a very important part of the patient record is electronically flagged now, and any medication that comes close to being a substance to cause a reaction is  questioned immediately.  We have to think before we decide to override a contraindication because of a previous recorded allergic response.

This new little button according to Dr. K will let us file a report for different levels of medical dysfunction.  A few weeks ago a mental health professional who shall remain nameless, was on call for about eight of our centers.  When a distraught mother with some serious concerns about her child wanted to speak to the mental health person on  call, I paged the person who was listed.  It took several pages to receive a response, and when he did call, he told me that he was in the woods, without a pen, and without his own phone. The most egregious statement he made was that he didn't feel comfortable calling this mother because "he didn't know her."  This is a systems issue, in fact, as he was appointed to take call and receive a salary for being available around the clock for mental health issues for eight health centers.  I unleashed a fury on him that I try not to display ordinarily.  It made one of my co-worker's jaw literally drop and it was the talk of others during the week.  Ultimately, this mental health person left the woods, found a phone, called the patient, and kissed my butt so I wouldn't report him.  

Dr. K said that I would have been justified in reporting this as an incident, which I could have done in any case, electronically or not.  I did tell  the head of our center about what transpired but he was not interested in listening to me at the time.  Dr. K told me that our reports, when done electronically, are critically reviewed and categorized by two preeminent women in the field of quality improvement who had developed the system at Children's Hospital.  Hopefully, by learning how to improve such breakdowns in communication and responsibility, the same scenario won't have to be endured over and over again.

Another issue which had plagues urgent care is the resulting of certain diagnostic tests.  A bilirubin test is one which is done frequently for newborns. It's been around forever and though it is a simple blood test, the yield is high in preventing unnecessary brain injury in newborns. During the weekend we get to evaluate many newborns for jaundice who were discharged from the hospital and now appeared bronzed.  Somewhere along the line, our lab stopped processing the bilirubin tests that they drew. We were told that they were out of reagent and so they sent them to either local hospitals or to a lab in Connecticut.  A test that could have been processed within an hour, with resultant planning for care, was taking six or eight hours for results.  Oftentimes, we were not even told which lab the blood was being sent to, thus making it nearly impossible to track down results.  This is not a small issue and could and should be the source of litigation. Dr K. again concurred that this would be a good reason for using the new tab.

We stayed at work for a half hour beyond our usual closing time, discussing cases of misplaced x-rays, incorrect Tamiflu dosing, and a few other examples of how Dr. K had used the reporting system.  If the reporting is not used as a club against people, we said that we hoped that it could end up, at least, starting to take aim at some persistent clinical issues.