Deadly Errors (21 page)

And saw:

Gram stain shows numerous white cells, a large degree of necrotic debris, and four plus gram negative rods. Cultures and sensitivities pending.

G
RAM NEGATIVE RODS?
Tyler vaguely remembered Brown saying something about gram positive cocci, not rods. A completely different type of bacteria. He checked the lab report from Torres’s earlier visit, the one prompting treatment with Ampicillin. Correct. Gram positive cocci were cultured from the original bacterial cultures.

Tyler leaned back and stared at the ceiling, mulling this over. “Huh!” He leaned forward, grabbed the telephone and dialed the Emergency Department and put on hold. A few moments later Brown picked up.

“John, Tyler. Look I was calling about our patient Torres.”

“Nice job, by the way. You ran out on me before I had a chance to thank you.”

“What I’m calling about is, do you remember the results of the original gram stain?”

“I’d have to look to be sure, but I’m almost certain it was gram positive cocci. Why?”

Tyler’s suspicions increased. “It’s now gram negative rods.”

Brown gave a long slow whistle. “Holy Mackerel! No wonder the bug juice didn’t touch him. Jesus. How could I have given him the wrong drug?.”

“Not necessarily. Maybe the abscess came from a different source. Blood borne, maybe.”

“Nice try, Tyler, but I wasn’t born yesterday. I screwed up if it’s gram negative.”

“Don’t be so sure,” he said. “Let’s see what the sensitivities come back as. Even treated otitis can become an abscess it if wants to.” In the background phone noise, Tyler heard Brown’s name paged over the intercom.

“Uh oh, gotta run.”

“Bye.”

Tyler sat back and thought it over again. Brown was a superb ER doc. Not one to make a mistake of that magnitude. He checked the chart again. The original culture clearly documented gram positive cocci, not gram negative rods.

Tyler burnt a copy of Torres’s prior lab results to CD. He knew full well that Khan, or anybody else with system administrator privileges, would be able to document the download if they were monitoring him, but so what? He was on record as having treated the patient in the ED. He had a perfect right to access this chart.

A plan began crystallizing in his mind.

F
IVE MINUTES LATER Tyler knocked on Yusef Khan’s open office door. Khan glanced up from a printout on his desk and smiled. “Yes Doctor, what is it I can be doing for you?”

Tyler entered the office. “I believe I’ve found another chart error.”

The man slid off his reading glasses and placed one stem in the corner of his mouth. “Another chart problem? Another one of your so-called hacker problems?” He grinned at Tyler.

“Yes,” he admitted, studying Khan’s reaction. “Only now I’ve changed my thinking. I don’t think a hacker’s the problem at all. I think the problem’s in the system. A bug in the software.”

The grin vanished from Khan’s face. “A bug in the system? What kind of bug?”

“One that corrupts database fields.”

“This is so?” Khan stiffened and removed the stem from the corner of his mouth. “You have proof of this?”

“Suddenly you’re interested, are you? Sorry to disappoint, but, no, I don’t have proof. I just have an example.” He gave him Torres’s name and chart number, then had him pull the chart up on the monitor. Tyler pointed out the problem with the initial gram stain and the one taken earlier and explained the resultant disastrous abscess from an erroneously treated infection.

“But can not they be different, these two infections?” Khan asked.

“Theoretically, yes. Probabilistically, no.”

“And why are you showing me this?”

Tyler’s turn to grin.
Gotcha!
“Because, my friend, if anything in that record changes now, you’ll have to believe me. Yes?”

F
ROM KHAN’S OFFICE Tyler headed straight for Jill Richardson’s office. When he got there her inner office door was closed. He said to her secretary, “I need to speak with Ms. Richardson, it’s important.”

Tony glanced at the wall clock. “She should be finished in another ten minutes if you’d like to wait outside. I’ll fetch you when she’s available.”

After making himself comfortable on a contemporary couch in the administration general waiting area, he pulled out his cellular phone and again dialed Robin Beck’s phone number. After ten rings he hung up. Still no answer.

After about fifteen minutes of cooling his heels, Tony floated forth to announce, “Ms. Richardson will see you now.”

She was leaning toward the computer monitor apparently catching up on email when he entered the office and closed the door.

Jill double clicked the mouse, then turned to him. “So, Doctor Mathews, what can I do for you?”

“I found another patient whose treatment was compromised because of a problem with the EMR.”

Her face turned serious. “Really! Tell me about it.”

Tyler told her how Torres’s bacteria had been erroneously reported as gram-negative rods when they probably really were gram-positive cocci and how this more than likely resulted in an inadequately treated infection becoming a life-threatening brain abscess.

“Couldn’t it be possible that both organisms were present initially and the antibiotics treated one, allowing the other to become the abscess?”

He shook his head. “Nope.”

She sat back, fingers steepled, tapping her lips, and seemed to consider his story. After a moment she said, “What do you plan to do?”

“Do? I’m doing it. I’m reporting this to you as head of Risk Management. And as such I expect
you
to do something about it. There’s a serious security flaw in the Med-InDx software.” He folded his arms and met her stare. “So, Ms. Richardson, what are
you
going to do about it?’

She studied her manicure. “I’m not a doctor but I doubt seriously you can prove those results were reported inaccurately.”

“The cultures will prove it.”

She shook her hair, then combed it back in place with her fingertips. “One case doesn’t prove anything.”

“Perhaps. But you and I both know there are other cases, don’t we?”

She didn’t answer.

He decided to push the gambit. “We both know there’s a problem with the medical record. The only way I can prove it is to find some other cases like mine. I want you to give me the names of any other patients who’ve had any complication you believe might have resulted from a record error.”

She cast a puzzled expression. “I’m not sure I understand where you’re coming from. I thought you didn’t have enough data to show there’s a problem. Now you do? On what basis?”

“Why is this sounding like you’re stonewalling? The more you and Khan insist there’s no problem, the more I think there is. All I’m asking is for you to help me do a root cause analysis. Are you telling me you—VP of Risk Management—refuse to investigate a problem that’s a potential risk to patient safety?”

“Are we back to the conspiracy theory now? Hackers and cover ups? Because if you are, I have to tell you I think that’s ridiculous. Yes, of course I know about any major complication that occurs in this medical center. I have to. That’s my job. Be proactive; make sure there’s nothing that’s going to result in adverse medical center exposure. And, if there is, enact the appropriate damage control. If there had been a serious concern about any computer security problems affecting patient safety, I’d know about it. There isn’t.”

“You’re blowing smoke at me, Ms. Richardson. Surely there are cases where physicians or nurses have blamed the system. Are you telling me there’s been nothing even close to that?” He locked eyes with her.

“I don’t understand why you’re so adamant about this hacker theory. Do you have any idea how much testing was done before we allowed that software to be installed and tested here? The HIPAA requirements alone required an entire extra layer of security. Do you really believe Med-InDx and Maynard would allow a flawed security system to be used on patients?”

Tyler laughed. “C’mon, you’re joking, right? No software system—especially one that’s still in development—is secure. Certainly not one that hasn’t been in wide spread use. Hell, look at Microsoft. They send out Windows patches every week and still don’t have it right. And that’s only an operating system, not a complete information system. Tell me you’re not trying to sell me on the possibility our EMR’s the one and only exception in the universe.” He shook his head slowly. “I won’t buy it.”

She seemed to consider this.

He added, “Look at it this way. Let’s say you’re right and nobody’s ever mentioned a problem before. Does that mean there isn’t one? One that no one knows about? Of course not. And if there is, it’s killing patients. Would you, as the head of risk management, like to stand by and know that possibility was never investigated?”

When she still didn’t answer he added, “I already know about Dr. Robin Beck. She claims there was a problem with the computer. So there must be others.”

She gave a resigned sigh and threw up both hands. “Alright already. I’ll give you the chart identifiers of three cases that struck me as suspicious,
but
only on one condition.”

“And that is?”

“If anything turns up, you’ll discuss it with me before doing anything foolish.”

Tyler punched his chest with a thumb. “Me do something foolish?”

She grimaced. “Especially you.” She paused, seemed to be thinking of something. “But for what it’s worth, you should also know a few things about Doctor Beck. The incident was investigated. She clearly made a mistake. Also, she’s an impaired physician. Alcohol and drugs. We have a long record of complaints about her. The incident you’re speaking of was the final straw. We had no choice but to let her go. She’s now got a ten million dollar malpractice suit against her on the case in question and that’s probably going to settle before the insurance company spends any more money on expert witnesses. And she’s now in rehab.”

“I still want to look at the record.”

W
ITH AN UNEASY gut feeling, Tyler approached the front door to the small, gray with white trim Dutch Colonial. Beck hadn’t answered any of his phone calls all day. That alone didn’t bother him as much as the fact no voice mail had picked up either. He didn’t know many doctors who made themselves totally unreachable. None that were successful, that is.

He rang the front door bell.

No answer.

He rang again.

Still no answer.

He took a cracked concrete path around the house to a postage-sized, dandelion-infested, patch of grass surrounded by a weathered cedar fence. A detached garage held a red Mazda Miata. Top down.

He walked up onto the back porch and peered through the glass window in the center of the door, saw a commercial grade stainless steel gas stove, a Subzero refrigerator matching white European style cabinets. Obviously remodeled within the past few years. A coffee mug sat on the Corian counter next to the sink. The well equipped kitchen of someone who likes to cook. Not the kitchen of a substance abuser.

He rang the back bell and pounded on the door.