Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open (New York)

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Placing medication orders on the wrong patient’s record, although uncommon, is an obvious patient safety hazard. Having multiple patient records open at the same time improves provider efficiency but may increase this risk of error. Based on expert opinion, the Office of the National Coordinator for Health Information Technology (ONC) and the Joint Commission issued recommendations that health systems limit the number of records displayed in electronic health records (EHRs) to one record at a time.

This project conducted a randomized comparative effectiveness trial to test the hypothesis that use of a restricted EHR configuration limiting one record open at a time would result in significantly fewer wrong-patient orders, versus an unrestricted configuration that allowed for up to four open records. The trial took place at a large academic medical center and a regional health system in New York that uses a single EHR vendor. Inpatient, emergency department, and outpatient providers were randomized to the restricted or unrestricted configurations.

The specific aims of the project were as follows:

  • Assess the relationship between the number of records open at the time of placing an order and the risk of placing an order on the wrong patient in a prospective, observational study. 
  • Compare the incidence of wrong-patient orders in a “restricted environment” that limits its providers to only one record open at a time to an “unrestricted environment” where users can open a maximum of four records at once in a randomized controlled trial. 

The trial randomized 3,356 providers who placed 12,140,298 orders in 4,486,631 order sessions for 543,490 patients. An order session is defined as a series of orders placed consecutively by a single provider for a single patient. There were no significant differences in wrong-patient order sessions in the restricted versus the unrestricted arm. Additionally, differences were not detected between the two arms for the per day median numbers of orders placed per provider and patients for whom orders were placed per provider. For measures of efficiency, there were no differences observed between trial arms, except for median daily number of keystrokes per provider (2,784 restricted versus 2,959 unrestricted, P < .0005). In the unrestricted arm, providers placed most orders with only one record open. However, providers in the emergency department placed nearly two-thirds of orders with two or more records open, and of all clinical settings placed the highest proportion of orders with the maximum of four records open.

The findings from the project did not support the expert opinion-based national recommendations to limit the number of records allowed open and suggest that health systems have flexibility in configuring their EHRs to accommodate the needs of their organizations. In addition, this trial underscores the importance of conducting randomized trials, when feasible, to evaluate safety interventions and recommendations.

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Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report

Adelman J. Assess Risk of Wrong Patient Errors in an EMR That Allows Multiple Records Open - Final Report. (Prepared by Columbia University under Grant No. R21 HS023704). Rockville, MD: Agency for Healthcare Research and Quality, 2019. (PDF, 451.19 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison).
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