A Case of Too Many Cooks in the Kitchen

Timothy R. Bone, President, MedMal Direct Insurance Company // December 12, 2011

The subject of conflicting orders in a medical chart is a modern one. Up to the 1950’s, the medical chart in the primary care setting was used as a reminder system for one physician to provide continuing care to a patient or to a patient’s family. All the family records were simply kept in one physical chart and only one healthcare provider made entries in that chart. Even in the hospital setting, all consultants were not allowed to enter an order into the medical record; rather, they were required to communicate with the house physician or the attending physician, who then entered the order into the medical record. Oh, how things have changed!

Issue: Conflicting, competing and incompatible drug orders written by multiple healthcare providers for a single patient.

A study done in the 1980’s expressed great surprise to find that as many as nine different physicians were involved in writing orders for one patient during a single 24 hour period. In today’s medical environment, this behavior has multiplied exponentially as other healthcare providers — such as nurse practitioners, physician assistants, nurse anesthetists, nurse midwives, and more — write orders in the medical record.

Solution: Minimize – not necessarily eliminate – multiple healthcare provider orders in the medical record.

Review Procedure: 
1. Obtain a sample of 50 charts of recently discharged patients, preferably including at least 10 patients who have been in the Intensive Care Unit (ICU) or the Coronary Care Unit (CCU). 
2. Review the order sheets – no more than three pages per chart – for the total number of healthcare providers who are actually writing orders, as well as the total number of orders written. 
3. Calculate the mean (i.e., the average!) number of healthcare providers per chart and the total number of orders per chart, then calculate the number of orders per healthcare provider. 
4. Review all of the charts for potentially conflicting orders where more than three “authors” have contributed, or where the average number of orders per “author” is less than five.

Actions to Be Taken:
1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next meeting. 
2. If problems exist, devise solutions and discuss them with your Medical Executive Committee and the medical staff. After a consensus has been achieved, implement the solution, with appropriate publication to the people who will be affected by it. As always, re-audit the issue within a given time frame and report to the Medical Executive Committee and the medical staff with your updated status report.

Added Point of Emphasis: The old rule concerning the etiology of medical malpractice lawsuits still applies: 50% arise from communication problems between human beings, 30% arise from system errors and 20% arise from actual clinical malpractice. By simply minimizing the number of authors in the medical record of a single patient, the frequency and severity of iatrogenic injury — and the subsequent medical malpractice litigation — can be decreased.