Health Ministry Finds 'Severe' Failures in ER Record-keeping

Surprise inspections by Health Ministry officials have uncovered potentially damaging failures to document emergency room procedures at state hospitals.

Haaretz has obtained the results of the inspections, which revealed medical files with incomplete listings of tests and critical medical data, illegible release papers, and patients released in violation of guidelines. Health ministry inspectors raided hospitals between 2004 and 2007 and their findings were transmitted to the hospitals in the past year as well as to the state comptroller. The State Comptroller's Office also examined the hospitals and its findings will be published shortly.

The team headed by Health Ministry controller Arieh Paz found failures to document release letters from emergency rooms.

These were "letters that are critical to patients continued treatment at medical institutions. These are severe findings," a senior official wrote.

As a result of the inspections, the Health Ministry and the Standards Institution of Israel have begun to develop a uniform, computerized emergency-room release letter for all hospitals.

The inspections examined hundreds of medical files and found some contained only partial medical data on emergency room patients. Patient temperature was noted in just half the files from Tel Aviv's Ichilov Hospital, 43 percent of files at Haifa's Bnei Zion Medical Center, 39 percent of files at Rambam Medical Center and 32 percent at Tel Hashomer Medical Center.

The best showing was Assaf Harofeh Hospital, where only 10 percent of files were missing that statistic.

Bnei Zion emergency room staff failed to note the heart rate in 32 percent of files. Twenty-four percent of Ichilov and 8 percent of Tel Hashomer files lacked this data. Rambam staff didn't document blood pressure in 31 percent of cases.

The names of medical staff are missing from many files, which could complicate follow-up efforts for patients.

Inspectors reported illegible handwriting on release forms on 25 percent of files from Holon's Wolfson Medical Center and 19 percent of files at Hadera's Hillel Yaffeh Medical Center.

At the Western Galilee Hospital in Nahariya, 93 percent of files failed to document the time of release from the emergency room.

It took staffers in the pediatric emergency room at Hillel Yaffeh 15 minutes to find on-call physicians, while at Ichilov inspectors found that some on-call doctors were not even in the emergency ward.

Twenty of 58 on-call doctors at Ichilov and 15 of 56 doctors on duty in the Tel Hashomer emergency room signed release forms they were not authorized to sign according to Health Ministry regulations. The practice was also found in Nahariya and Bnei Zion.

Rambam is the only hospital in Israel to recently install a computerized system to document medical procedures, eliminating handwritten records and missing data. Medical staff there now use laptop computers to document every stage of treatment.

The Health Ministry noted that the computerization project is slated for installation in all Israeli hospitals within a year. The ministry also said a shortage of hospital beds has created overcrowding, which it is addressing with the Finance Ministry at this time.

The hospitals responded to the results of the inspections by stating that documentation standards have improved since the series of visits. Nonetheless, some failures found are still relevant, as illegible or missing release records cannot be retrieved.

Tel Hashomer stated that about 30 percent of emergency room patients are admitted for minor orthopedic trauma such as sprains, which do not necessitate recording vital signs. The hospital called this a misunderstanding by inspectors and not a problem. The hospital also stated that all release records are signed by an appropriate doctor, however the inspectors saw copies that remain in the emergency room, which do not all show that signature.

Rambam stated it has made major changes in the six years since the inspection including tripling its size and computerizing its files.

Ichilov stated that since 2004 most of the failures had been repaired, save the legibility of doctors' handwriting, which will be resolved with the computerization of all emergency rooms.

Nahariya hospital stated that temperature is not relevant in diagnosing orthopedic or surgical trauma and that doctors who signed release papers had special permission from the Health Ministry to do so, rendering the criticism unjustified.

Hillel Yaffeh responded that the results of the 2006 inspection have been addressed and improved since that time.

Assaf Harofeh stated that the hospital administration regularly examines admittance and release procedures to improve the operation of one of Israel's most crowded emergency rooms and that some of the problems revealed in the inspection will be resolved with the implementation of a computerization system.

Bnei Zion stated that vital signs are now taken from orthopedic patients and release times are recorded in a computer system. They added they had "resolved anything necessary."

Wolfson stated that it had acted immediately upon receipt of the report to resolve failures.