Overreliance on its electronic health record system was one of the mistakes Texas Health Resources made that led to the misdiagnosis and release of a patient later confirmed to have Ebola, according to a report from an expert panel convened by the Dallas-based health system.
The report outlines the mistakes that lead to the release of Thomas Eric Duncan from the hospital last October--who later died from the disease--and improvements Texas Health can make to avoid mistakes from happening again.
One of the mistakes, according to the report, was "inadequate communication processes and overreliance on the electronic health record to convey critical information."
Processes in the emergency department "did not optimally address the early identification of Ebola or other emerging diseases during the first ED visit, nor did [the hospital] optimally utilize the full capability of the electronic health record," the report says.
At the time of his admittance to the hospital, Duncan told a nurse he had recently traveled to Africa. The nurse recorded the information into the hospital's EHR system, but the information was not displayed in the physician's EHR view, Texas Health said at the time. However, a clarification less than a day later from the hospital said the information was available to the full team and did not account for the misdiagnosis.
The panel report said that in the EHR, travel history would be accessible to everyone in the emergency department. However, to view the information, a clinician would have to look beyond the initial patient assessment screen to access travel history.
To correct this, Texas Health had its IT team update the record so the clinician could select from a list of specific countries visited by the patient and also added an alert to enact steps to manage a suspected Ebola patient.
Going forward, THR and other health systems should question how the EHR can be customized to support high quality of care and include tailored alerts, as needed, the report notes. To do so, there will need to be a better understanding of how information is communicated in a care team setting, how EHRs are used and how to improve clinicians' "situation awareness," it says.
To learn more:
- read the report (.pdf)