A psychiatric consultation was requested from a surgical specialty service for a “50 year old female with seizure disorder has been refusing Dilantin and had a seizure last night. Please comment on competency to refuse medication”. The surgeon was not aware that the patient was delirious. The patient was disoriented to time and place, did not realize she needed medication or why she was in the hospital. The psychiatric resident consultant learned the patient was in the hospital for revision of a previous orthopedic procedure. In searching the patient’s medical records on the hospital computer he learned the patient had previous surgery for a pituitary tumor and that her seizure disorder was a complication of that surgery. As a result of the surgery the patient also had pan-hypopituitarism and required replacement hormones in order to live. These replacement hormones had not been prescribed on her admission to the ward. The patient now exhibited severe and life-threatening complications of the deprivation of these hormones. When the problem was called to the attention of the charge resident he said “OK, I’ll get the intern on it”. He seemed quite unconcerned about the error, “I guess she did not have her medications with her when she came in”. When the psychiatric consultant returned to follow the patient’s course later in the day he found that the intern’s solution had been to request an Endocrine consult rather than to prescribe the medication. Hence nothing had changed.

Fortunately for this patient there may be multiple overlapping levels of investigation, supervision, and consultation in teaching or tertiary hospitals. Often a patient has many doctors, a medical student, intern, resident, chief resident or fellow, and attending physician. Consultants, often many of them, may also be involved in complex cases. Nurses have their own hierarchy and patterns of supervision. This is useful, potentially life saving redundancy of medical care. It is considered wasteful by some administrators who see no advantage and only cost in duplicating services. Fairly commonly psychiatric consultants pick up errors in diagnosis or treatment, not because they are more brilliant or knowledgeable, but because they may spend more time with the patient, may listen more attentively, and elicit a more detailed history. However in this case the patient’s entire medical history, including the operative summary and required medications were in the hospital computer. Computerized medical information can be a great aid to patient care but it must be read and understood. The intern did not read the history but limited his involvement to the routine orthopedic procedure. However, this was not a routine patient. The nurses did not note the medications in the patient’s computer record and question why they were not being prescribed in the hospital. In this example no one but the psychiatric consultant read the computer data and obtained a complete history. One cause of this error is the acceleration of patient care. Interns, residents and nurses are overworked. Contacts with patients are too brief. History taking may not be duplicated by physicians involved in the case (Christakis, 1997). In hospitals and in mental health agencies there is less redundancy than in the past. Psychiatrists tend to be relegated to prescribing medications rather than coordinating care. Progressively less trained people are providing direct patient care with less supervision and consultation. Independent functioning is often imposed on those who are not yet mature enough in experience and judgment to avoid error like the intern in the case just described.

Knowledge base: computerized medical records, medication error (omission), serious complication, consultation, psychiatric consultation, institutional immunity, time pressure, culture of safety, medical care (narrow), nursing care, pharmacy computer error? (lack of check for outpatient medications?)

Dorpat, T. (1992), Doctor abuse and the interactional dynamics of graduate medical training., International Journal of Communicative Psychoanalysis and Psychiatry, 7 (1), 39-48. Dorpat discusses the interactional dynamics involved in abuses in medical training: fatigue, sleep-deprivation and extended working hours.