A woman seen at an Illinois emergency room for a puncture wound from a gardening tool died of tetanus. Tetanus has a high fatality rate and there is no cure once it is developed, but the tetanus vaccine provides high levels of protection, even when given after a wound is sustained. (Tetanus generally takes several days to incubate after a puncture wound that delivers the C. tetani spore, caused by an object that may have been exposed to feces, such as any object outdoors.)
Upon receipt of a threatening puncture wound, it is recommended that a patient be given a tetanus booster if it has been more than five years since an immunization has been given. It is unclear when the woman had last had a tetanus booster, but if status is unknown, giving a booster is also recommended. Despite coming to the emergency room for a puncture wound that was threatening with an unknown immunization status, the woman did not receive a tetanus shot. We can look into the details of the case in a Cause Map, or root cause analysis. This format diagrams the cause-and-effect relationships that led to an issue – in this case, the death of a patient from tetanus despite seeking treatment from a hospital.
In this case, the woman died of tetanus because she was infected with tetanus by being stabbed with a garden fork (for reasons which are unclear), and because she was not effectively immunized against tetanus. The patient was ineffectively immunized because she did not receive the recommended tetanus immunization.
During the patient’s intake by a nurse, the immunization status in the patient’s electronic health record (EHR) was selected as “unknown/ past 5 years”. The physician treating the woman did not request any clarification, but apparently considered that her shots were up-to-date and did not order a booster. This clearly indicates a poor design in the EHR as an “unknown” status would indicate the need for a booster, and having a shot within the “past 5 years” would not.
This confusion illustrates the issues being seen during the increased use of electronic health records. In their report Health IT and Patient Safety: Building Safer Systems for Better Care by the Institute of Medicine, they state, “designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences.” A review by a medical malpractice insurer showed that EHR issues were involved in only 1% of lawsuits concluded from 2007 to 2013 but that percentage had doubled from 2013 to early 2014, and more are expected with the increased adoption of EHRs. This is disappointing news for an incentive program for the use of EHRs, which hoped they would make hospitals safer. Data on whether or not that has occurred is mixed.
Because of their concerns, the Institute of Medicine has recommended the creation of an information technology (IT) safety center to investigate EHR risks. So far the proposal has not been funded by Congress. Others think that a government-supported fund to compensate victims, similar to that used for vaccine injuries, may be necessary.
The Office of the National Coordinator for Health Information Technology has released a guide on identifying and addressing unsafe conditions associated with health IT (available by clicking here). It calls for providers, EHR developers and policymakers to ensure health IT is used to improve patient care and protect patient safety.
To view the Cause Map of the tetanus death, please click on “Download PDF” above. To learn more about identifying and addressing unsafe conditions associated with health IT, click here.