Misdiagnosis Caused by Improper Health Record

Introduction

Regardless of the size of the health facility or specialization, managing patient information and clinical records is essential. Due to this, clinical facilities are adopting the use of Electronic Health Records (EHR) in their daily operations. The EHR software device is proving useful in consolidating patient records and storing the information in a digital package, where it cannot be easily lost. In addition to record keeping, health facilities need an interdisciplinary approach workflow to minimize clinical errors such as misdiagnosis and medical omissions that may affect the service provision and efficiency. However, the case study presents a health facility that lacks both functional interdisciplinary team and poor record keeping. The emergency department did not have a proper EHR system to record the clinical chart of Mr. Jones, which led to the omission of an important element of his medical history, leading to underservice and readmission. When the patient visited the department previously, the nurse failed to record all the important records in the EHR, which interfered with diagnosis in the successive medical services, leading to numerous safety concerns.

Some of the Major Contributors to Misdiagnosis

The misdiagnosis occurred because there was evidence of poor use of informatics. The nurse that cared for Mr. Jones in his previous visit to the Ed did not observe the principle of meaningful use of metrics. Even though the facility boasts of electronic health records, the responsible attendant did not take time to record all the clinical information of the patient in the EHR. Health records are essential in ensuring the success of service provision by enhancing diagnosis. Normally, clinical conditions reoccur or have close relationships (Katongole et al., 2022). In addition, nurses use the medical histories of patients for diagnosis and developing treatment options. It is therefore important for nurses to include all health information in the electronic health record for future use. However, in the case study, even though Mr. Jones had attended the ED and was diagnosed with a cardiovascular condition, the health attendant failed to include all the essential information in the records.

Second, the misdiagnosis was caused by fragmentation of care. Some individuals are fond of changing doctors for healthcare needs. Seeking healthcare from different nurses cause the experts to have various pictures of a single patient’s health, which may lead to the creation of many opportunities for significant symptoms or missed medical test (Katongole et al., 2022). In the case study, the patient is involved in fragment care from both the personal physician and the Emergency Department. Mr. Jones seeks healthcare needs from both the ED and personal physician, which has made the two groups have different pictures of his health. The ED nurse could not recall the actual health picture of Mr. Jones since he had been missing for long from the facility’s records.

Third, the misdiagnosis was caused by a lack of time with the patient. The nurse in question did not spend enough time with Mr. Jones to conduct a comprehensive diagnosis. The patient was not in a good state of mind and therefore needed some time to regain his senses (Schroeder et al., 2022). His memory sense had been affected by his medical condition, and as a result, he could not recall his previous treatment records. In such a case, the nurse ought to have given him more time to settle before concluding the diagnosis. However, the nurse rushed the diagnosis process, leading to the costly omission and wrong test results.

Safety Concerns Related to Jones’s Care

The first safety concern for Mr. Jones’s care was medication/drug error. The misdiagnosis of patient Jones’s medical case could have led to a medication error. Since the nurse failed to conduct an accurate diagnosis, the subdural hematoma treatment was not provided, which caused the patient to collapse at night (Dai & Zhang, 2022). In addition, Mr. Jones was subjected to BMP and CBC tests which were unnecessary. Instead of taking the patient through an EKG, dig level, and CT scan, the nurses ordered different medical procedures, which only led to the worsening of the patient’s condition.

The second safety concern of Mr. Jones’s case was comatose. The misdiagnosis prevented the patient from receiving the right treatment, leading to the worsening of his condition and getting into a comatose state. Terminal illnesses such as cardiovascular diseases are emergency cases which are delicate and do not leave room for mistakes. Any medical error for such patients is always costly and can lead to death or coma. From the medical history, Mr. Jones was a victim of a terminal disease and thus required urgent medical intervention. However, the misdiagnosis altered the right healthcare, which was suitable for his case, leading him to a comatose.

The Pertinence of the Omitted Information

Digoxin drug slows down the heart rate and improves the filling of the ventricles with blood. Victims of cardiovascular, their heart rate and ventricle blood volume are always affected. Patients suffering from atrial fibrillation, in particular, experience irregular heartbeat characterized by a unique volume of blood pumping. In this case, Mr. Jones is a victim of atrial fibrillation with an irregular heartbeat and abnormal blood pumping. However, the information was omitted, preventing the patient from being subjected to the electrocardiogram (Anwar et al., 2022). If the medical record had been provided, MR. Jones would be taken through an electrocardiogram to record the electrical signal from his heart thereby checking his heart condition and developing the necessary medical intervention. The omission however led the patient’s condition to worsen and subsequently go into a comatose state.

The omitted information can be integrated into the electronic health record by the physician after conducting the diagnostic testing and establishing the heart condition. Following the revelation of the patient’s atrial fibrillation, the physician should subject Mr. Jones to an electrocardiogram to check his heart condition and then record the result in the Emergency Department’s EHR. Additionally, the clinician should record all the medications set for the patient in the electric health record.

Meaningful Use of Metric to be Considered

When recording the health information in the EHR, the physician ensures the records meet the 5 pillars of the health outcomes policy priority of improving quality, safety, efficiency, and reducing health disparities. Health information is not just kept for the sake of keeping records but must align with the clinical objectives, enhance their attainment, and be properly communicated (El Emam et al., 2022). In the case study, the physician must use the 5 health pillars as a guide while using the electric health record. The health record must be recorded in a way that is easily shared and exchanged to improve Mr. Jones’s care.

Ways in which IP and EHR Could have Improved Mr. Jones’s Care

The impatient hospital contains complete stay records for patients enrolled for inpatient services. Electric health records contain all the patients’ records regarding medical history, medication, and progress notes among other important health information (Cook et al., 2022). The two documents are critical for future diagnosis and decision on the next course of action and could have helped in the examination and medical intervention for Mr. Jones. The record could have shown his history of atrial fibrillation and guided the physician to recommend an electrocardiogram test to check his heart condition and initiate the necessary treatment. With the two records, similar issues would not be witnessed because the examination will be properly and accurately done.

Three Recommendations for Improving Quality Care

The first recommendation for the Emergency Department is to have a functional interdisciplinary team for proper workflow. In the incident, the ED does not witness different professionals working together for quality workflow with proper communication channels, which leads to the omission. There is no collaboration between the different experts in the department, starting from the nurses, physicians, and other medical specialists to achieve quality medical service. It is this poor interdisciplinary approach that led to the misdiagnosis.

Second, the ED should have a proper and functional inpatient hospital to record the health information of patients enrolled for inpatient services. The medical records for all patients that spend at the facility under the care of nurses, physicians, and any health expert should be kept well for future reference. The record will assist when dealing with patients who would be seeking healthcare for the second time. For example, in this case, Mr. Jones had been treated in the ED, but the facility did not keep his health records, leading to misdiagnosis.

Finally, the Emergency Department should observe the meaningful use of metrics by recording all the health information of their patients in the EHR. Every patient receiving healthcare from the facility should be properly assessed, and the results should be kept in the EHR of the ED. In addition, the ED should become used to conducting additional diagnostic testing for patients to adjust and review the medical information stored in the electronic health record, considering health is dynamic.

Conclusion

In summary, the case study shows an example of the consequences of misdiagnosis and the importance of keeping patient health information. Mr. Jones’s misdiagnosis and subsequent deterioration in health were caused by the failure of the ED to keep his health records well. In addition, the case study has demonstrated how a single medical error of misdiagnosis can be costly for the patient. To prevent similar issues from the occurrence, medical practitioners must observe the meaningful use of metrics in their daily interactions with patients.

References

Anwar, M. N., Khan, U. A., Khakwani, A. S., Saeed, I., Ishfaq, H., Muslim, M. O., & Anwaar, M. F. (2022). Digoxin use in atrial fibrillation; Insights from national ambulatory medical care survey. Current Problems in Cardiology, 101209. Web.

Cook, L. A., Sachs, J., & Weiskopf, N. G. (2022). The quality of social determinants data in the electronic health record: A systematic review. Journal of the American Medical Informatics Association, 29(1), 187-196. Web.

Dai, N., & Zhang, W. (2022). Ultrasonic diagnosis of breast fibroadenoma and analysis of causes of misdiagnosis. Chinese Journal of Medical Ultrasound (Electronic Edition), 19(10), 1103. Web.

El Emam, K., Mosquera, L., Fang, X., & El-Hussuna, A. (2022). Utility metrics for evaluating synthetic health data generation methods: Validation study. JMIR Medical Informatics, 10(4), e35734. Web.

Katongole, S. P., Akweongo, P., Anguyo, R., Kasozi, D. E., & Adomah-Afari, A. (2022). Prevalence and classification of misdiagnosis among hospitalised patients in five general hospitals of Central Uganda. Clinical Audit, 65-77. Web.

Schroeder, R. M., Stunkel, L., Gowder, M. T. A., Kendall, E., Wilson, B., Nagia, L. & Van Stavern, G. P. (2022). Misdiagnosis of third nerve palsy. Journal of Neuro-Ophthalmology, 42(1), 121-125. Web.