Ebola in Dallas

Swerlick, Robert A rswerli at EMORY.EDU
Mon Oct 6 13:33:37 UTC 2014

A busy ED physician faces a deluge of information and the ratio of signal to noise is small. The electronic health record used is not such much an information management tool. The key pieces of information needed to avoid the most recent embarrassment are hidden in various nooks and crannies of the record. I am reminded of reading the series of "Where's Waldo" books to my children at bedtime, desperately trying to find Waldo in the mass of tiny cartoon characters. The only difference is I don't even know what I am looking for in the medical record.

Why didn't the ED physician read the nurses notes? The same reason s/he did not read every other page in the record. Whether justified or not, I suspect that the nursing notes may be filled with lots of extraneous information (noise) which seldom had been essential to assimilate to make decisions.

 Industries which have gone further in terms of cracking this information management nut have figured out ways of putting important information in front of key decision makers when they are called upon to make decisions. As we delegate information collection to other parties, this is going to become an even larger issue.

Bob Swerlick

-----Original Message-----
From: Joe Graedon [mailto:jgraedon at GMAIL.COM]
Sent: Sunday, October 05, 2014 8:43 PM
Subject: Re: [IMPROVEDX] Ebola in Dallas

Guessing a very busy ER and a harried MD made a quick decision that turned out to be wrong.

Here is our take on the passing of the buck:


Joe Graedon

On Oct 5, 2014, at 6:31 PM, David L Meyers <dm0015 at ICLOUD.COM> wrote:

> It appears that the cause of improving diagnosis in medicine was given an unfortunate boost in Dallas this week with the (mis)handling of the nation's first case of ebola both at the clinical and public health levels, that is already having risk management and public policy effects.  With respect to the actual care of the patient, who was not diagnosed until his second ED visit several days after his first one to the same ED, the full story remains to be elucidated, but we've witnessed the painful release of information followed by corrections and restatements that too often characterize events of this sort.
> Initially, a nurse seemed to be the culprit blamed for obtaining critical information about travel history from the Liberian patient recently arrived in Dallas from Lagos via Brussels and Washington and not passing it on the health care team or following the CDC guidelines for handling such patients, said to be in place at the hospital.  Next, blame focused on the failure of the EHR to properly communicate information between the nurse and subsequent providers including the treating physician. The latest information seems to be that the physician had the information and made a wrong decision regarding diagnosis, management and disposition; whether s/he acquired relevant history independently or from the EHR is not clear.
> More information and analysis is trickling in and it will be sometime before most of the facts are known, but it is clear there were human errors and system errors which contributed to the situation. This may wind up being the most studied case of diagnostic error to date with the greatest potential to alter how the public sees this problem.  I imagine the IOM committee now addressing this subject will have some very instructive material to work with.  Root cause analysis anyone?
> Here's a chronicle of the events as pieced together by the Dallas
> Morning News.  Interesting reading.
> http://www.dallasnews.com/news/metro/20141004-dallas-ebola-case-shows-
> even-sound-plans-can-fail-spectacularly.ece
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
> Society for Improving Diagnosis in Medicine
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Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine

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