I’m a big fan of multitasking. Really I am. But doctors administering drugs and operating on patients should not be checking text messages. Nope, nope nope.
That’s the harrowing conclusion of a recent case study published last month by the Agency for Healthcare Research and Quality, a federal agency, and written by the chief information officer at Harvard Medical School. It’s a nearly deadly example of “distracted doctoring,” an issue we wrote about last month. Here, in brief, is a tale of medical multitasking gone wrong:
Before the feeding-tube procedure, the doctors increased the patient’s dose of anticoagulation medicine to reduce his risk of stroke. After the procedure, the doctors held a meeting about the case. They decided the patient needed an echocardiogram, a heart image, to determine whether to continue the blood-thinning medication.
During the meeting, the attending doctor instructed the medical resident (a junior doctor) to order the anticoagulation treatment temporarily stopped. The resident began to enter that order into her phone using a computerized doctor order entry system. These are increasingly common systems that can be used on phones or tablets.
Before the resident could finish the order, her phone beeped with an incoming text. It was from a friend. She got lost in the text and failed to finish the order. The patient continued to get the blood thinner at the elevated dose he was getting before the feeding-tube procedure.
On the patient’s fourth day in the hospital, his heart raced and he was gulping for air. He was rushed into emergency open-heart surgery. Blood had filled the sack around the heart. He’d received too much blood thinner, but he survived.