It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic. Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview: “…we got many donated ventilators. Many … Continue reading It’s like having 10 different remote controls for 10 different TVs

This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic.

Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview:

“…we got many donated ventilators. Many hospitals got that, and we needed them. … But it’s like having 10 different remote controls for 10 different TVs. It takes some time to figure that out. And we definitely saw things go wrong as people struggled to figure out how this remote control works from that one.”

“We had many patients being transferred from overloaded hospitals. And when patients come in a batch of 10 or 20, 30, 40, it is really a setup for things going wrong. So you have to be extremely careful in keeping the patients distinguished. We have to have a system set up to accept the transfers … [and] take the time to carefully sort patients out, especially if every patient comes with the same diagnosis, it is easy to mix patients up.”

And my favorite, even though it isn’t necessarily COVID-19 related:

“For example, … [with] a patient with diabetes … it won’t let me just put “diabetes.” It has to pick out one of the 50 possible variations of on- or off- insulin — with kidney problems, with neurologic problems and to what degree, in what stage — which are important, but I know that it’s there for billing. And each time I’m about to write about it, these 25 different things pop up and I have to address them right now. But of course, I’m not thinking about the billing diagnosis. I want to think about the diabetes. But this gets in the way of my train of thought. And it distracts me. And so I lose what I’m doing if I have to attend to these many things. And that’s really kind of the theme of medical records in the electronic form is that they’re made to be simple for billing and they’re not as logical, or they don’t think in the same logical way that clinicians do.”