August 2003 Bulletin

Patient safety tip from Dr. Herndon–Risks of distraction

A recent editorial in USA Today critical of drivers who don't pay attention to their driving by eating, drinking, reading or talking on a cell phone ("careless drivers") also described doctors who are affected by a host of distractions while caring for their patients ("careless doctors"). Doctors have the power to save lives and prevent errors by paying closer attention to the care they provide–especially the tests they order for their patients.

In my early career in medicine, if one of my patients had an abnormal lab test or biopsy, I received a phone call from the lab or pathologist who informed me of the result. If one of my patients had an abnormal X-ray such as a lesion on a preoperative chest X-ray, I received a call from the radiologist who warned me of the abnormality. In turn, I could easily inform the patient and provide appropriate follow-up care, consultation or order additional studies.

Today these events don't occur! Everything is computerized; I don't receive a personal phone call and I suspect most of you don't either. The problem is that each of us must remember and review the results of every test, study or X-ray we order and inform the patient of the results–an almost impossible task considering the large number of patients we care for and their rapid throughput in our offices and hospitals.

Delay in treatment is one of the 19 sentinel events reported by the Joint Commission on Accreditation of Healthcare Organizations. In the Academy's closed claims studies, inadequate reporting or communication, failure to act on test results, avoidable delays in diagnosis and the use of inappropriate tests have increased among orthopaedic surgeons between 2000 and 2002. Physicians need a reliable mechanism for learning about abnormal studies and for communicating those abnormal results to the OR team as well as to the patient.

As noted by Bates and Gewande in a recent issue of in the New England Journal of Medicine, "many errors result from inadequate access to clinical data." Many serious laboratory or radiological abnormalities require urgent action. If these problems were reported to clinicians automatically, the "time to the administration of appropriate treatment is reduced by 11% and the duration of dangerous conditions in patients is reduced by 29%."

Such alerts must be built into our systems of care electronically. One example (there are many) is the notification of a critical laboratory result or X-ray (clinical alert) by a hand-held device or cellular telephone. Each of us should make every effort to have such a mechanism available in our work environment. It won't be easy, but we must demand it for the improved safety of our patients.

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