When the wrong history repeats itself

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.