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

Project Final Report (PDF, 451.19 KB) Disclaimer

Project Details -
Completed

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.

Leveraging Health IT to Test Solutions That Are Replicable, Scalable, and Improve Patient Safety

Impact

“Studies like that by Adelman and colleagues point the way to the creation of a digital learning health care system, in which the results of the interactions between clinicians (and, increasingly, patients and families) and the EHR are analyzed to help guide the strategies that lead to the highest value and most satisfying care. Having spent tens of billions of dollars digitating the health care system, it is essential to take advantage of the unique capacity of digital tools to allow clinicians and health care systems to learn from every click.” -editorial by Drs. Wachter, Murray, and Adler-Milstein4

Wrong-patient errors can affect any patient in any healthcare setting for a variety of reasons.

Dr. Jason Adelman, named as one of 50 experts leading the field of patient safety in 2018 by Becker’s Hospital Review,2 has led multiple AHRQ Health IT-funded research efforts centered on health IT safety. The research of Dr. Adelman, Executive Director of Patient Safety Research at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, is widespread and being replicated by other organizations. Dr. Adelman is part of the ECRI Patient Safety Collaborative, where he is advising several hospitals on how to implement the Wrong-Patient Retract-and-Reorder (RAR) Measure that he developed to evaluate the frequency of wrong-patient errors that occur through CPOE systems. When a clinician places an order, then cancels the order and places the same order for a different patient within the next 10 minutes, the measure flags it as a wrong-patient RAR event. While capturing the instance of retracting and reordering mistakes does not correct or prevent errors, it provides the facility with information to discover error trends along with opportunities to intercept processes that lead to such errors. Using such data as evidence of the CPOE’s potential impact on patient safety, decision makers can factor RAR measures in choosing one health IT design over another.

Having multiple EHRs open simultaneously does not increase wrong-patient orders.

“Placing orders on the wrong patient should never happen. Yet, human error is very common in the healthcare environment. Healthcare is inherently complex and heavily reliant on people rather than technology to protect patients from harm. It will likely take a multi-pronged health IT approach to prevent these types of errors.”
- Dr. Jason Adelman

Dr. Adelman’s AHRQ Health IT-funded research found that restricting clinicians to having one EHR record open at a time did not significantly reduce the rate of wrong-patient order errors compared with allowing up to four records to be open concurrently. His work did not support the ONC and Joint Commission recommendation that EHR systems should only allow one record to be displayed at a time. In the study, published in the May 14, 2019 issue of JAMA,3 using the RAR measure, Dr. Adelman and his team compared the risk of wrong-patient orders while accessing one versus four records open in a variety of clinical settings, including hospitals, EDs, and outpatient facilities. While no differences in wrong-patient orders were observed between those clinician groups, there was considerable variation in the frequency of errors in different clinical settings. The rate of wrong-patient order errors was lowest in outpatient settings, where physicians may care for one patient at a time. The highest rates, meanwhile, were seen in inpatient critical care and obstetrics units, which reflected differences in workflows and number of patients being cared for simultaneously, researchers noted. The research offers insights for healthcare systems that are trying to balance patient safety with the needs of busy clinicians who need tools for efficient workflow.

The right patient, right dose, right medication, right route, and right frequency.

The Health IT Program has also funded Dr. Adelman to extend research on RAR, to validate and evaluate the reliability of RAR using a different EHR system, so it can be implemented and may advance interventions to prevent these serious and complicated safety issues. The intent is to develop health IT measures that identify deviations from the Five Rights of Medication Safety: right patient, right dose, right medication, right route, and right frequency.

Use of photographs to prevent errors.

An additional Adelman-led, AHRQ-funded study is assessing the effectiveness of using patient photographs as an additional identifier in the EHR system to avoid wrong-patient errors when using CPOE systems. The research team will conduct a randomized controlled trial of wrong-patient error rates between systems with patient photos and without. Ultimately, the team plans to develop a toolkit with guidance to help other health systems in implementing patient photos in EHR systems.

2 https://www.beckershospitalreview.com/lists/50-experts-leading-the-field-of-patient-safety-2018.html

3 https://jamanetwork.com/journals/jama/fullarticle/2733207

4 https://jamanetwork.com/journals/jama/article-abstract/2733189