Medical error and liability: How technology can be a safeguard

As discussed previously, the emergence of a "reasonable physician" standard of care affects both human and veterinary practitioners, defining our approach to error management. Under this standard, adverse events previously defensible by deference to custom might now result in decisions of negligence if it is determined that such events were easily preventable.

The tremendous financial growth of the veterinary profession, as well as the human-animal bond, have concomitantly increased legal attention to this field.

The number of veterinary graduates entering post-graduate specialty programs and private practice has been accelerating for a decade. There are many 15-to 30-doctor general and specialty-care practices nationwide, some producing annual gross revenue between $8 million and $15 million. The growth of pet health insurance encourages clients to seek these newly advanced — but expensive — specialty services.

Traditional small-animal veterinary practices that attracted little legal attention now complement corporate providers such as VCA Animal Hospitals and Banfield, the Pet Hospital, each of which employs more than 1,000 veterinarians and thousands of receptionists and technicians. These corporate chains evince the growth of the profession but also provide deep-pocket targets for would-be litigants.

Legal value of human-animal bond

Much attention has been given to the legal value of the human-animal bond in recent years. Court rulings in Kentucky and Pennsylvania allowed non-economic damages for pet loss when the conduct of defendants was determined to be outrageous. An Illlinois statute allows for open-ended non-economic damages for pet loss when the defendant's conduct meets the law's definition of aggravated cruelty or animal torture. It also allows clients to recover the cost of their legal fees. This non-economic damage movement in veterinary medicine (as well as the separate but related guardianship movement) is noteworthy for the deluge of legal attention it foists on the veterinary profession.

Additionally, the fact that there are three editions of an Animal Law casebook has helped prompt more than 60 law schools to offer or plan to offer animal-law courses, reading groups, and/or seminars. Irrespective of its merits, animal legal-rights activity is enhancing liability risks for veterinarians.

The human-animal bond moves more clients to seek a perceived higher quality of care assumed to come from board-certified specialists. Secondary-care centers composed of emergency clinicians and a cross-section of specialists now offer 24/7/365 veterinary care for companion animals. They have intensive-care departments that offer CT and MRI scanning, ultrasound and fluoroscopic imaging. They offer kidney transplants for animals in renal failure and advanced chemo and radiation therapy for pets with cancer. Each of these advances brings with it the same potential for human error that befalls the human health-care profession, and all of the previously mentioned factors combine to define a landscape in veterinary medicine that is vastly different from what it was even 15 years ago.

Technology in error reduction

Just 100 years ago, the average human life expectancy was 40 years. By 1990 it had increased to 74 years. Longer life spans, quality of life and health improvements can be attributed in large part to advancements in computer technology.

Information technology (IT) can play an important role in medical-error reduction, too. Some industries, particularly aerospace and nuclear power, already use it to good effect. For example, airplane cockpits have numerous warning systems that provide pilots regular feedback on cabin environment, engines, surrounding airspace, weather patterns and ground conditions. Pilots remain in constant contact with air-traffic control towers, which in turn continuously relay information.

Most jets are now equipped with an Enhanced Ground Proximity Warning System (EGPWS), which provides a 60-second advance warning of approaching hazardous terrain. Planes have sophisticated flight-data recorders that track multiple conditions simultaneously during flight. In the event of an accident, this data can be retrieved to help assess any errors.

The impetus for these advances is the need for safe air travel, which has been ensured in large part by their implementation. More than 10 million airplane takeoffs and landings now occur each year with an average of fewer than four crashes annually.

Similarly, the Three Mile Island incident near Harrisburg, Pa., in the late 1970s prompted the nuclear-power industry to implement technology to reduce errors. Systems for nuclear-plant error detection and prevention are improving dramatically.

Similar opportunities exist for IT to help reduce errors in the human and veterinary medical professions. In human medicine, IT stores patient histories and much related data. Medical Information Systems (MIS) are in wide use in hospitals and clinics. Such systems allow problems with verbal and written communication, including misinterpretation of illegible written orders, to be obviated by efficient text-conversion software and other electronic systems. Thus, serious efforts in the appropriate use of information technology will result in less costly and more appropriate care.

Technology also helps reduce dependence on human memory for drug choices, dosages, interactions and calculations for all types of medical treatments. Errors involving medication are among the most common in human medicine; while they rarely carry significant consequence, the number that do result in adverse drug events and/or iatrogenic injuries is deemed to be greater than is socially or legally acceptable.

Recent meta-analyses found an overall incidence of 6.5 percent to 6.7 percent for serious adverse drug reactions in hospitals and determined that between 28 percent and 56 percent of these were preventable.

It is well known in medical circles that it is exactly these types of human errors that the aeronautical and nuclear industries have attempted to eliminate.

A recent study tested physicians' knowledge of potential drug interactions against a computer system designed to detect those interactions. The physicians fared poorly in comparison.However, several implementations of information systems are proving to reduce errors considerably, and many others have great potential but have not yet received enough study. A partial list of these interventions includes computerized physician order entries, computerized physician decision supports, robots for filling prescriptions, bar coding, automated dispensing devices and computerization of the medication administration record.

Useful technological tools

Computerized physician order entry (CPOE) is a system for physicians to prescribe pharmaceuticals online, and has probably had the biggest impact of any automated intervention in reducing medication errors.

The rate of serious errors fell 55 percent in one study, and the rate of all errors fell 83 percent in another.The benefits of CPOE are:

1. Ordering is structured so that information such as dosage, route and interval have to be included.

2. Orders are legible and the prescriber can be identified.

3. Patient information can be provided to the prescriber during ordering.

4. Orders can be checked for discrepancies such as allergies, drug inter-actions, drug-laboratory conflicts and information about the drug as it relates to a patient's liver and kidney status.

CPOE can be augmented by computerized decision support — shown to be especially important in preventing errors that actually result in injury. Such systems can synthesize and integrate patient-specific information, perform complex evaluation and present the results to clinicians in a timely fashion.

The CDSS uses a series of point-and-click steps to walk the physician through a diagnostic process while suggesting questions and bringing together data inputs from various sources.

As an adjunct to both CPOE and CDSS, some facilities have implemented a wireless alerting system that transmits real-time alerts to clinicians through alphanumeric pagers, cell phones or personal digital assistants (PDAs).

Electronic prescribing has helped reduce prescription, dispensing and administrative errors.

The use of robots to fill prescriptions has been shown to reduce errors and free pharmacists to handle more complex prescription issues requiring judgment and knowledge.

Bar coding of drugs, patients and staff will ensure that the correct drug is dispensed to the right patient at the appropriate time while logging this information into an automated medication record.

Automated dispensing devices also would be used to assure that indicated drugs are available when appropriate. PDAs and tablet computers also offer remedies for error reduction.

IT and liability

As demonstrated previously in our discussion of the T.J. Hooper case (Feb. 2008, p. 56), technology has played a role in the determination of appropriate industry standards since the 1930s.

The Helling case additionally evinced the shift to a "reasonable physician" standard of care, which has since been followed by similar determinations.

With these two cases in mind, we might ask if information technology could be implicated in the determination of a "reasonable" physician's actions.

In fact, this link is material.

In Vasquez v. Albertson's, a Texas district court jury found a physician negligent for writing an illegible prescription to which the jury attributed the patient's death. The pharmacist, a co-defendant, was held liable for guessing what the doctor had written.

This case established the precedent of physician negligence for illegible handwriting and provides a powerful argument in favor of electronic prescribing.

According to one legal expert, "Handwritten prescriptions should be relegated to the past. Pharmacies should insist on typed prescriptions at a minimum and encourage medical professionals to transmit prescriptions electronically. Physicians and pharmacies will have better records of medications, dosages prescribed and instructions for use. This in turn allows fewer chances for error (and resulting legal liability). Electronic transmission also will facilitate electronic access to prescribed medication records by patients and their physicians."

The Vasquez case demonstrates the salience of this discussion about information technology in medicine; the issue of illegible prescriptions is only one among many potential sources of medical errors.

IT advances in veterinary medicine

While human and veterinary medicine share many similarities, there obviously are many differences to consider, not the least of which is the vast range of patient conformations and physiologies in veterinary medicine.

Both professions treat many similar illnesses and benefit from the same or similar technologies. But significant differences exist between the two professions' ability to finance research and technological progress, as well as clients' willingness or ability to pay for increasingly expensive care.

This lack of resources is a particularly limiting variable in private practices, where the small size of the practice and amount of information technology available and used is considerably less than in human medicine.

The immense growth of the veterinary profession in recent years sparks hope that the margin of difference will continue to shrink, but veterinarians should strive to incorporate what measures are available in the interim.

Unlike human medicine, where there is increased reliance on IT, most private veterinary clinics still record and organize patient data on charts. Banfield is an exception. It uses a computerized information network called PetWare to manage medical records and client accounts for more than 500 hospitals and millions of animals.

The system downloads and provides information on prior visits, precautionary alerts by attending veterinarians, drug dosage recommendations and inquiries for prescribed treatment regimens. As a reference to attending veterinarians, recognized anesthesia protocols are accessible for review prior to a procedure.

The system offers Web-based training programs for veterinarians and clinic staff. PetWare then logs completed training programs for future employee reference. The veterinary profession as a whole can benefit from data gleaned from the system through cooperative research studies.

Individual technologies, particularly the Personal Digital Assistant (PDA) and tablet computer, hold particular promise for the veterinary profession but are perhaps underused in veterinary medicine as clinical resources.

The impact of PDAs in human medicine is already being felt, and as many as 95 percent of physicians are using them for some aspect of patient care. They offer immediate access to stored references for pharmaceutical information, including dose volume and administration, possible drug interactions and electronic means for prescribing drugs. Electronic versions of popular clinical references (including veterinary references) can also be installed for quick access. A non-exhaustive list of such programs available for the PDA include drug indexes, IV drip calculators, blood and fluid volume calculations and medical references, all of which can be stored on expansion cards. PDAs are a relatively inexpensive ($200 to $500) yet important means to reduce potential medical errors and streamline the course of daily clinical practice.

With the advent of technology for wireless modems and a wireless Internet access system, PDAs can send and receive information via the Internet. This has allowed development of systems to link PDAs to hospital medical records, so that clinicians can access up-to-date patient information, as well as electronically prescribe drugs using their PDA.

PDAs work well as vehicles for the CDSSs discussed earlier, as well as other generically labeled "point of care" (POC) medical information systems.

The PDA can prompt, suggest, remind and safeguard against human error. One expert says "Hand-held devices (PDAs and tablet computers) ... have the potential to make patient records and traditional medical and nursing charts obsolete." Such technology need not be limited to doctors; many nurses use them as well.

Tablet computers

Tablet computers manufactured by companies such as Fujitsu and Acer, sold with Vet Ed Tablet™ software, are touch-screen driven like PDAs. The software includes veterinary reference materials on drugs, dosages and differential diagnoses as well as excellent client and staff video education programs. This allow users to print or write on patients' medical record templates or, e.g., on the Hill's Atlas of Anatomy on the tablet's screen, convert the letters to text and send these customized documents wirelessly to the practice's printers or server. Copies can be sent home with clients, e-mailed to them or permanently stored in patients' computerized medical charts.

Clients can sign informed consents on the screen, as with UPS deliveries, and copies can be stored electronically in patients' records, helping to make practices truly paperless. Tablet computers weigh less than 3.5 pounds and can easily be transported into and out of exam rooms or vehicles.

Both PDAs and tablet computers are being evaluated in veterinary teaching and clinical environments and, while most studies are preliminary, results are generally positive. Inasmuch as organizational culture appears to factor heavily into the usage of instructional technology, its continued and expanded use in teaching environments will likely be of significant importance in producing "IT-friendly" clinicians.

Conclusion

Errors are a fact of life and are attributable to human nature. Human error has been studied in-depth for years. Of particular interest has been the study of errors in high-risk industries such as aerospace and nuclear power, which subsequently attracted much attention to the need for error reduction in the medical field.

The rate of error in human medicine is well documented and staggeringly high. The soaring costs of professional liability insurance for physicians and hospitals is forcing human medicine to take steps to reduce error rates.

As veterinarians, it can be assumed that we commit just as many errors and for the same reasons. Reducing them in the interest of better patient care should be a priority.

The changing legal environment regarding medical and surgical standards of care amplifies the importance of error reduction.

"Reasonable" physician conduct in the wake of an adverse event now can be assessed in terms of what preventive actions might have been implemented, rather than what actions are customary.

The wealth of data available regarding potential methods for error reduction must be taken into account when analyzing adverse outcomes.

Of these potential methods, information technology has already demonstrated effectiveness and continues to hold untapped potential.

Its availability and cost-to-benefit ratio render its absence in the veterinary practice setting an almost-certain liability.