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Lack Of Information Synthesis: One Of The Most Important Causes Of Medical Errors

As I travel around the country, working in the trenches of various hospitals, I’ve been struck by the number of errors made by physicians and nurses whose administrative burden distracts them from patient care. The clinicians who make the errors are intelligent and competent – and they feel badly when an error is made. However, the volume of tasks required of them in a day (many of which are designed to fulfill an administrative “patient safety” or “quality enhancement” process) makes it impossible for them to complete any task in a comprehensive and thoughtful manner. In the end, administrators’ responses to increased error frequency is to increase error tracking and demand further documentation that leads to less time with patients and more errors overall. It’s a vicious cycle that people aren’t talking about enough.

As I receive patient admissions from various referral hospitals, I rarely find a comprehensive discharge summary or full history and physical exam document that provides an accurate and complete account of the patient’s health status. Most of the documentation is poorly synthesized, scattered throughout reams of EMR-generated duplicative and irrelevant minutiae. Interpreting and sifting through this electronic data adds hours to my work day. Most physicians don’t bother to sift – which is why important information is missed in the mad dash to treat more patients per day than can be done safely and thoroughly.

I have personally witnessed many critical misdiagnoses caused by sloppy and rushed medical evaluations. I have had to transfer patients back to their originating surgical hospitals (at some of America’s top academic centers) for further work up and treatment, and have uncovered everything from cancer to brain disorders to medication errors for patients who had been evaluated and treated by many other specialists before me. No one seems to have the time to take a long hard look at these patients, and so they end up undergoing knee-jerk treatments for partially thought through diagnoses. The quality of medical care in which I’ve been engaged (over the past 20 years) has taken a dramatic turn for the worse because of volume overload (fueled by diminishing reimbursement) in the setting of excessive administrative and documentation requirements.

To use an analogy – The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up.

What we require most in healthcare is time to process our thoughts and engage in information synthesis. We must give physicians the time they need to complete a full, comprehensive, evaluation of each patient at regular intervals. We need nurses to be freed from desk clerk and safety documentation activities to actually inspect and manage their patients and alert physicians to new information.

Until hospitals and administrators recognize that more data does not result in better care, and that intelligent information synthesis (which requires clinician time, not computer algorithms) is the foundation of error prevention, I do not foresee a bright future for patients in this manic assembly line of a healthcare system.


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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