Posted by Bill Sandweg on 03 September 2018.
Banner Health is big. Not only is it the largest health care system in the state of Arizona, it is our largest employer as well. When it has computer problems, many patients are likely to be affected. This was the case last fall in Tucson.
The problems arose as a result of Banner’s merger with the University of Arizona’s Health Network. This brought a number of southern Arizona hospitals and clinics under the Banner umbrella. As with any merger, there were issues blending the two entities. One of the issues was that each of the entities was using a different electronic medical record keeping system. So that medical records, billings and ordering systems could be consistent throughout the system, the entities had to get on a single system. The decision was made to have the southern Arizona locations convert to the record keeping system already in use in Banner’s other locations. Any conversion would be expected to produce some problems. The problems with this conversion were substantial and affected patient care in some instances, according to a recent story in the Arizona Daily Star.
The Star investigated the transition and made a public records request to the Arizona Department of Health Services to see what records it had of problems arising from the transition. What it received was heavily redacted but showed adverse effects on some patients and lots of staff frustration. Banner, while admitting delays in getting patients registered, delays in ordering and receiving lab results and delays in ordering and receiving medications, denied that any patients were injured.
Since the problems affected all of the newly acquired southern Arizona facilities, some of the patients affected by the delays in getting medications and test results were patients who were critically ill. The records of the Department of Health Services showed that, despite Banner’s denials, some patients were indeed harmed. At least one substantiated complaint showed that there was a delay in treating a patient due to an inability to use the new computer system which resulted in a deterioration of the patient’s condition which required the patient be intubated.
A resident physician was mistaken by the system for an attending physician. Residents are medical school graduates who are still in training and who practice under the supervision of an attending physician. The difference is an important one.
There was at least one “near miss” reported where a physician ordered a too large dose of a medication for an infant. The error occurred because the old system and the new system recorded patient weight differently and the dosage was based on weight. The error was caught by a nurse before the infant was overmedicated.
A retired physician was quoted in the story describing the problems he experienced as a patient in getting his cancer treated during the transition period. He reported delays and confusion. He had to keep after people to get done what he knew needed to be done. He wondered what would have happened had he not been as knowledgeable about his condition and treatment as he was. What would have happened if he just assumed that his doctor’s office was doing what needed to be done, he wondered.
The retired doctor should be an example to all of us. Learn as much as you can about your condition and its treatment. Ask questions. Do not assume that no news is good news, if you don’t hear back about a test result. Keep after providers to get the tests, examinations and treatment you believe you need or have them explain to your satisfaction why you don’t need it. A passive patient who gets injured because the doctor’s office didn’t follow through will be blamed for her inaction, should she bring suit. “Blame the patient.” is a major defense in medical malpractice cases. Don’t let it happen to you. Be proactive.