Comedy of Errors
Administrators require emergency nurses to document a lot of crap that has nothing to do with the patient's actual emergency condition. We have domestic violence screening questions, tuberculosis screening questions, immunization status queries, and so on and so on. These add a significant amount of time and effort to the triage process. Fortunately, we now use electronic medical records which have little checkboxes for those questions in order to speed up the process.
I'm not certain, but I suspect these boxes must be checked or else the triage note cannot be completed. The combination of these two faulty systems sometimes results in unintentional comedy:
1) 6 month old with fever and cough. Denies suicidal ideation. (He is crying a lot though. Maybe he's depressed)
2) 55 year old with CPR in progress. Denies flu-like symptoms. (Stop compressions! Have you been coughing? Any fever? Hello!?!)
3) 35 year old assaulted by spouse, facial contusions, lip laceration. Admits to being threatened by others. (Bet the nurse felt silly asking that one)
I'm not certain, but I suspect these boxes must be checked or else the triage note cannot be completed. The combination of these two faulty systems sometimes results in unintentional comedy:
1) 6 month old with fever and cough. Denies suicidal ideation. (He is crying a lot though. Maybe he's depressed)
2) 55 year old with CPR in progress. Denies flu-like symptoms. (Stop compressions! Have you been coughing? Any fever? Hello!?!)
3) 35 year old assaulted by spouse, facial contusions, lip laceration. Admits to being threatened by others. (Bet the nurse felt silly asking that one)
Labels: EMR, pencil-pushing idiots, WTF
posted by scalpel at 7:15 AM
13 Comments:
Last time I was in the ER for post-RFA cardiac arrhythmia, the tech handed me a urine cup when I asked to use the restroom. Really? You think my pre-existing SVT is caused by a UTI? Anyway, at the time I also had a broken hand so I just pointed out that there was no way I could give him a clean catch, but I still wonder what the hell protocol calls for urine cultures for arrhythmias.
Nah, you can skip whatever you want during the triage process; your chart just gets reviewed by The Man and there is a chance you get a nastygram. Luckily, The Powers That Be have just announced we don't have to screen each patient for "ability to pay for food" and "nutritional deficiencies" ("have you lost greater than 10 lbs in the last 4 months that you were not trying to lose?") in the ER anymore. There is absolutely nothing that we're going to do with that info---we're not going to show up at their houses and make them dinner.
JHACO and assorted like-minded idiots assert that their intentions are to enhance quality of care. I'll believe that when administrators run around like maniacs in advance of the next inspection, exhorting us to close our wounds more securely, prescribe our medications more accurately, assess our patients better. Do they ever do that? Hell, no! All they care about is documentation, policy guidelines being in place, and process. The actual provision of medical care is done with a surpassingly high level of quality and competence at the vast majority of American hospitals. Where there are problems, scurrying around in advance of an inspection to make sure that verbal orders are properly signed, forbidden abbreviations are not used, ad nuseam, will do nothing to improve quality except that of job security of the JCAHO and like folks. Screening infants for suicidal ideation creates jobs but does nothing to enhance care- I doubt it actually does anything even for adults who are considering doing away with themselves. Care to calculate the NNT for that one?
I'm a hospice nurse, visiting folks at home. Our EMR drives us all crazy. We are expected to ask each and every patient how they feel on a scale of 1-10 about each and every symptom they may be having including but not limited to:
pain
constipation
sleep disturbance
nausea
edema
anticipatory grief
difficulty urinating
confusion
weakness (and IF we could change
your weakness, what number would you like it to be? Uh, how about ZERO).....
lonliness
need for reassurance
...and the list may go on and on.
There are also symptoms for the primary caregiver (mainly related to the level of their anticipatory grief) to rate on the 1-10 scale as well.
Patients and caregivers also must be asked at what number they would find their pain, sleeplessness, etc., tolerable.
Not very many terminally ill people really have the patience or the ability to rate each and every symptom.
A lot of people either ignore the question or become confused by it. We try make appropriate, educated guesses based on the info given by the patient and/or caregiver.
We hate it.
nice..
Our nurses have to ask everyone if they were exposed to Tuberculosis recently. "Oh yeah! Now that you mention it, my friend has consumption!"
I love these forms.
My favorites are the ones that people print out off the internet with the same insane questions and they fill them out in insane detail "in 1957 I felt threatened when a classmate punched me".
One of our nurses dutifully asked a healthy, well built adult man "Do you feel safe in your home?" Ans: NO.
She was surprised so continued the questioning...Well there are some scary drug dealer types in the neighborhood, never sure when they might try to break in........Well now, how might the ER address that situation? You asked.......
JCAHO - bringing unfunded and unneeded mandates to the ED, because it is job security for JCAHO and other bureaucrats everywhere.
;-) That was cute. Those forms can be real annoying for us patients, too.
My favorite JHACO maneuver:
removing patient identification from everything visible (privacy!) . . . . .
and then discovering a year or two later that mistakes were being made due to failure to properly identify the patient.
I await their report "Water is
Wet and Fire is Hot" since they are such geniuses!
I am on the systems management team for a very large [pee in the jar, get your blood drawn] company.
We have a catchphrase for what you're describing:
"Yet Another Example Of A Situation Where A [Software] Developer Should Be Beaten With Large Sticks"
William, I'm not convinced that beating the software developers is any more likely to make either their managers or the people writing the specifications listen to them.
Many of us who design software systems for a living have as good an understanding as you do, or often better, of the risks of putting computers together with various kinds of medical situations, from controlling machines delivering radiation therapy to, yes, computerized medical records. Have a look through the archives of the Risks Forum for years of history on this.
Risk management is in large part an engineering discipline, combined with a good bit of understanding how people work (as opposed to how one wishes they would work). When the messy, complex realities of this combine with the way other people (many of the managers) wish the way the world worked, you end up with computers programmed not only to do dumb things, but even asking people to do dumb things.
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