Patient Safety Tip of the Week

March 11, 2014

We Miss the Graphic Flowchart!



In our Patient Safety Tips of the Week for December 29, 2009 “Recognizing Deteriorating Patients” and September 11, 2012 “In Search of the Ideal Early Warning Score” we lamented the fact that, ironically, the switch from paper to electronic health records may have made it more difficult to identify deteriorating patients. Some of the EMR’s don’t provide easy access to a graphic flow chart similar to the paper vital signs flowchart that always sat on top of the patient chart.


Apparently we’re not the only ones who miss the graphic flowchart! This month an article on implementation of an early warning system echoed the same problem (Fung 2014). When a hospital implemented their new system they used a new form that, unlike their prior form, did not represent the vital signs and other physiological parameters in a trend graph form. Because of concerns about the lack of such graphic representation, the authors developed scenarios to test their hypothesis that the lack of such representation might make it harder to identify clinical deterioration. Six clinical scenarios (low-grade temperature, spiking temperature, tachypnea, Cushing’s response, hypovolemic shock and normal observations) were identically depicted on old and new charts and given to one hundred health-care professionals who were asked to study each of the charts, and the time taken to give a diagnosis was recorded.


The old chart (the one with the graphic display) was associated with faster responses in all of the scenarios, reaching statistical significance in 5 of the 6 scenarios. Additionally, the response was more accurate in all of the scenarios, reaching statistical significance in 3 of the 6 scenarios. Overall, response to the old chart was 1.6 times faster and 15% more accurate than the new chart!


And the lack of a graphic display affects things other than early warning systems. In our May 28, 2013 Patient Safety Tip of the Week “The Neglected Medications: IV Fluids” we noted that problems managing fluid status may have actually worsened as an unintended consequence of technology. In the old days, the first thing we saw when we opened a patient’s chart or walked into their room was a flow sheet that had their vital signs, their I&O’s (input and output), and their weight all represented in graphic form. It was pretty easy to spot bothersome trends. Many of today’s EHR’s, however, don’t provide such graphically displayed data (or at least don’t make it easy to get to such displays in just a click). Theoretically, computers should make it easier to track fluid status. The computer should be able to be programmed to compare the fluid input to the measured output and perform a calculation of the estimated insensible losses, then display the net fluid deficit or excess in a graphic form along with the patient’s weight. You could even program in alerts when deficits or excesses are above whatever limit you set (or at least display those unwanted values in red), keeping in mind we want to avoid alert fatigue.


Similarly, on the outpatient side, some diagnostic errors might be avoided if there were better graphic display of some parameters (see our May 15, 2012 Patient Safety Tip of the Week “Diagnostic Error: Chapter 3”). For example, it is often difficult to recognize that a patient has had a significant weight loss when you typically just look at the last visit note and compare the weight from that visit to today’s visit. Putting patient weights in graphic form may help us recognize trends (weight gain or loss) that may be significant clues or red flags about the patient’s condition.


Add to the problem the notorious fact that nurses’ notes go largely unread by physicians in the EHR (see our March 22, 2011 Patient Safety Tip of the WeekAn EMR Feature Detrimental to Teamwork and Patient Safety”) and it’s no wonder signs of clinical deterioration get missed.


Simply put – some things are more easily recognizable when they are in graphic form. So IT vendors: get with it!!! Computers should easily be able to represent these parameters in a graphic format. They should also be able to highlight significant trends in red or other bright color to draw our eye to such trends. And they need to make these graphic flowcharts readily accessible. If it takes more than 2 mouse clicks to get to them, they will be underutilized.


Visual display of early warning system data has been used successfully (Rothman 2013, Finlay 2014). The Rothman Index (RI) is a composite measure of 26 variables readily available in most EMR’s. Variables include input from vital signs, laboratory values, cardiac rhythm, the Braden Scale, and nursing assessment and the RI can be updated automatically every time new clinical information is input. The RI can be displayed graphically to alert clinicians to acute changes in patient status as they happen (Rothman 2013). A recent study  (Finlay 2014) demonstrated the RI to be superior to the MEWS in several respects.





See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:



Some of our other columns on early warning systems or recognition of clinical deterioration:


·        February 26, 2008 “Nightmares: The Hospital at Night

·        April 2009 “Early Emergency Team Calls Reduce Serious Adverse Events

·        December 15, 2009 “The Weekend Effect

·        December 29, 2009 “Recognizing Deteriorating Patients

·        February 22, 2011 “Rethinking Alarms

·        March 15, 2011 “Early Warnings for Sepsis

·        October 18, 2011 “High Risk Surgical Patients

·        March 2012 “Value of an Expanded Early Warning System Score

·        September 11, 2012 “In Search of the Ideal Early Warning Score

·        May 2013 “Ireland First to Adopt National Early Warning Score

·        September 17, 2013 “First MEWS, Now PEWS

·        January 2014 “It MEOWS But Doesn’t Purr







Fung K, Khan F, Dawson J.The Introduction of an Integrated Early Warning Score Observation Chart–A Picture Paints a Thousand Words. Journal of Patient Safety 2014; 10(1): 13–19



Rothman MJ, Rothman SI, Beals J. Development and validation of a continuous measure of patient condition using the Electronic Medical Record Original Research Article
Journal of Biomedical Informatics 2013; 46(5): 837-848



Finlay GD, Rothman MJ, Smith RA. Measuring the modified early warning score and the Rothman Index: Advantages of utilizing the electronic medical record in an early warning system. Journal of Hospital Medicine 2014; 9(2): 116–119,





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