One of the first admonitions physicians receive when being trained on electronic health records (EHR) is to avoid cutting and pasting text from one medical record to another. A wrong-sided surgery case shows how using text created by a referring physician added yet another dimension to an unfortunate string of errors.
A 53-year gentleman with cerebral palsy and on medication for bipolar disorder visited the emergency room with bloody urine. The radiologist’s impression of a CT scan ordered for renal calculi suggested a mass on the left kidney, though an addendum posted 90 minutes later noted in bold type that “the previously noted renal mass is located within the ** RIGHT ** kidney, not the left as initially reported.” A subsequent abdominal CT scan with contrast also received the same addendum later in the day to correct conflicting references within that document as to “left” and “right.”
Early that afternoon, the patient’s care was transferred to Dr. U, a urologist. Dr. U noted, “renal mass, left” in his assessment and he described his plan to refer the patient to Dr. US, a urological surgeon in the same medical group, for consideration of a nephrectomy.
When Dr. US saw the patient a week later, he noted, “CT reviewed” and charted that the patient most likely suffered from a renal cell carcinoma versus transitional cell cancer. In his problem list, Dr. US wrote “cancer of kidney” and “renal mass, left” and in his assessment he noted, “left renal mass.”
After concluding that a total laparoscopic nephrectomy was an appropriate plan for his patient, Dr. US scheduled surgery at a different hospital than that of the patient’s ER visit. In his pre-operative report, Dr. US dictated a diagnosis of a left renal mass and that the patient was to be admitted for a left laparoscopic radical nephrectomy and possible total ureterectomy, depending on the intraoperative pathology. The anesthesiologist’s pre-operative checklist indicated a left-sided procedure.
On the day of surgery, Dr. US attempted, but was unable, to access the images taken during the patient’s ER visit.
With those images unavailable, Dr. US relied on his notes, dictations, markings, and the patient’s consent, all of which referenced a left-sided tumor, and proceeded to remove the left kidney. When the intraoperative pathology report confirmed the lack of a mass in the kidney, Dr. US had the patient closed. After the surgery, Dr. US noted the addenda to the original CT reports as to left and right and explained what had happened to the patient’s family.
The patient and Dr. US came to an informal resolution over the medical care provided.
In a subsequent administrative action, an accusation filed against Dr. US commented on the fact that Dr. U and Dr. US shared the same electronic health record system and pointed out that Dr. US’s initial history borrowed a paragraph directly from Dr. U’s record. While that paragraph in itself did not address the left-side- right-side issue, the administrative complaint went on to accuse Dr. US of having “cloned” Dr. U’s notes and that he “carried forward” Dr. U’s notation of a left-sided tumor into his own record.
Dr. US’s discipline from the Medical Board included completing PACE courses in wrong-sided surgery and in medical record keeping.
Certainly, the case presented many more issues than similarities in the electronic records of Dr. U and Dr. US. But sometimes, a step that may have been taken to save time can end up sharing the stage in a much larger tragedy.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
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