Swiss Cheese Model

The Ebola Miss: A System Breakdown

Unless you have been living under a rock, you probably have noticed there has been some panic over the ebola virus making its way to the US recently. One of the major aspects of of the coverage has been around the case of Thomas Duncan, the patient who died from ebola after the ER initially missed the diagnosis. 

Naturally, there has been a lot of blame going around on how such a thing could be missed. What intrigued me was the initial statement from Texas Health Presbyterian Hospital Dallas blamed their EMR for the miss, and then the statement was retracted days later.  The follow up statement from EPIC saying there is “no flaw” in their system has caused strong reactions, ranging from scathing to defensive to general eye rolling within the Health IT community. 

It is no secret that there is a lot of dissatisfaction with EMRs and Health IT in general. I have already written about the AMA jumping in with their recommendations to improve EHR usability. To add to this, a new report is indicating that nurse satisfaction with EMRs has hit a new low. Through my many years as a UX designer in healthcare, I have personally heard all kinds of horror stories of poor EMR design. These problems make it is very easy to point the finger at the EMR vendors. The reality is, poorly designed health IT systems are just part of the problem. 

Healthcare is a system: it consists of various clinicians with various specialities, working together in high stress environments, using different tools and technology (including EMRs), with different rules, regulations, and reimbursement policies hanging over their heads. Oh yeah, and the most important piece at the center of all of this is the patient needing treatment. The University of Wisconsin SEIPS model provides an easy way to see the complexities of a healthcare system.

Let’s look at the Environment piece of the situation. The ER is an overwhelming place to work. A patient with a fever is not going to stand out in such a crazed environment where mistakes can easily be made. Add the cultural aspect where doctors are trained not to assume rare diseases and “look for zebras”. Let’s be fair - when have we ever discussed the issue of ebola in the US before this (and no, the movie “Outbreak” doesn’t count.) These factors were just part of the systemic error that caused the ebola miss. 

Vamsi Aribindi explains the systemic breakdown of the situation very well. He points out four (not one) errors that led to Mr. Duncan being sent back home when he should have been immediately admitted. A lying patient, missed communication, a crazed environment, and a key piece of information not on the physician screen of the EMR were all holes in the swiss cheese

What bothers me about the situation is that there continues to be a blame culture in healthcare after years of Patient Safety research have shown errors such as this are to system breakdowns. There is usually not “one throat to choke”. I realize that pointing blame is basic human nature, but the discussion should initially start at how can we avoid this from ever happening again. Once the appropriate investigations are done, the key lessons need to be shared for the entire healthcare system to benefit. 

It is important to remember EMRs are just a tool in the healthcare system meant to treat patients. Many have treated EMRs and technology in general as a “silver bullet”. Unfortunately, silver bullets rarely fix big systemic issues, especially when they have their own set of flaws.