Series on Multi-tasking – Negative outcomes

A 56-year-old man with dementia was admitted to a medical center. His feeding tube needed to be removed from his stomach. It’s a common enough procedure that went fine. But then things went terribly wrong. The culprit: a smartphone. That’s the harrowing conclusion of a recent case study published by the Agency for Healthcare Research and Quality, a federal agency, and written by the chief information officer at Harvard Medical School. It’s a nearly deadly example of “distracted doctoring”.

Here, in brief, is a tale of medical multitasking gone wrong:Before the feeding-tube procedure, the doctors increased the patient’s dose of anticoagulation medicine to reduce his risk of stroke. After the procedure, the doctors held a meeting about the case. They decided the patient needed an echocardiogram, a heart image, to determine whether to continue the blood-thinning medication.

During the meeting, the attending doctor instructed the medical resident (a junior doctor) to order the anti-coagulation treatment temporarily stopped. The resident began to enter that order into her phone using a computerized doctor order entry system. These are increasingly common systems that can be used on phones or tablets.

Before the resident could finish the order, her phone beeped with an incoming text. It was from a friend. She got lost in the text and failed to finish the order. The patient continued to get the blood thinner at the elevated dose he was getting before the feeding-tube procedure.

On the patient’s fourth day in the hospital, his heart raced and he was gulping for air. He was rushed into emergency open-heart surgery. Blood had filled the sack around the heart. He’d received too much blood thinner, but he survived.

Dr. John Halamka, who wrote the anonymous case study (name of hospital, patient and doctors withheld), writes that hospitals have to figure a way to balance the benefits of interactive technology with the risks of distraction.“Providers should be ensuring that routine personal issues/interruptions do not impact the delivery of quality care,” he writes.