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2012 YP Award Essay 1
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2012 Winner - Essay 1

The Doctors Company Foundation Young Physicians Patient Safety Award


Bull—-,” Mr. A swore at us after we suggested obtaining yet another imaging study for him. Oddly enough, he didn’t say it with spite, anger, or even disrespect. He had simply had enough. Seven months into my third year of medical school, I had seen plenty of patients declining treatment which we, the medical team, had suggested. What made this case different, however, was that it was Mr. A.


Mr. A was practically an establishment on my monthlong rotation at this hospital—he had been there on my first day, and he was there 24 days later on my final week. He suffered from a complex host of medical problems including pulmonary fibrosis, severe hypertension, and renal failure, but I always looked forward to seeing him on morning rounds. Without exception, he was friendly, courteous, and cooperative. He had patiently endured numerous uncomfortable diagnostic procedures as we gradually brought his illnesses under control.


Late one evening, Mr. A began to vomit uncontrollably and felt excruciating chest pain. A troponin level revealed that he had suffered a non-ST elevation myocardial infarction. The next morning, Dr. X, the resident taking care of Mr. A, was entering a note on the computer when he noted only three or four medications on the automatically generated medication list, where there had been dozens just one morning before. As it turns out, the electronic medical orders system used at this hospital required all medication orders to include an expiration date. At admission, the resident on duty overnight had selected a date which, at the time, seemed to be far into the distant future. Nobody had considered that Mr. A might actually stay past that date.


And so as the expiration date arrived, the computer system automatically discontinued Mr. A’s anti-hypertensives, and as a result, he suffered a myocardial infarction. The medication change had gone unnoticed by his human caretakers, who entered notes which contained automatically-generated medication lists. And with that, Mr. A’s heart was damaged, physically and emotionally. His medications were restarted, but his once-optimistic spirit could not be recovered. Though still courteous, he denied any further treatment or diagnostics and insisted that he be transferred to a nearby rehabilitation center.


The mistake had not only harmed Mr. A physiologically; it had eroded his trust in our team. It was impossible for us to care for him effectively anymore. A number of small holes in the delivery of care had come together in an unfortunate storm: our system required an expiration date, our computers deleted medications without notification, our medication lists were generated without being checked by his human providers, and a nurse delivered medications without noting that only a quarter of Mr. A’s usual pills were being given. It all came back to one crucial failure of imagination—the inability to imagine that Mr. A might be much sicker than thought, and might stay at the hospital much longer than originally envisioned.


The most startling thing about Mr. A’s story is that I had previously considered our computerized medication lists to be a marvelous invention. Tedious handwritten medication lists were the bane of residents and students alike when I rotated at other hospitals, and the electronic, automatic medication lists were one small blessing when dealing with complex patients who invariably presented with dozens of medications. Reviewing them and writing a list by hand always seemed frustrating and tedious—a waste of time before we could do genuine, intellectually engaging medical analysis.To us, checking patient safety was something we did before we could practice real medicine.


While Mr. A’s story undoubtedly suggests many improvements that must be made across many levels in this example, this is the one that stands out most clearly to me: we made the mistake of confusing computing power and convenience for intelligent and careful attention. While electronic orders bring many conveniences, they also increase the risk for mistakes such as this without proper attention and diligence. Since seeing Mr. A go to rehabilitation, changed for the worse, I have made it a point to personally review each patient’s medication lists and administration schedules daily. While patient safety does not always feel like new and adventurous intellectual ground, Mr. A taught me a painful lesson about its importance. I hope to never take it for granted again.


*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.


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