Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors

Abstract

IMPORTANCE Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. OBJECTIVE To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. INTERVENTIONS Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). MAIN OUTCOMES AND MEASURES The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). RESULTS Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20];

Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors

“…An order session was defined as a collection of orders that were consecutively placed by the same practitioner for the same patient; if any order in the session qualified for RAR, the entire session would be considered as an RAR event in this analysis. 4 Fourth, we modified the multivariable regression model to include a random intercept for each practitioner to assess whether practitioner-level variation played a significant role in the rate of WPOE errors. We conducted all analyses using R statistical software, version 3.5.0 (R Project for Statistical Computing).…”

“…Wrong-patient order entry (WPOE) represents an important type of error. Although studies indicate that practitioners place more than 99.9% of all orders for the correct patient, [1][2][3][4] the large number of orders placed by practitioners each day suggests that even an error rate of less than 1 in 1000 orders would still lead to approximately 600 000 orders placed for the wrong patient annually in the US. 4 Wrong-patient order entry occurs more frequently in the emergency department (ED), with its rate estimated to be up to 2 per 1000 orders.…”

“…Although studies indicate that practitioners place more than 99.9% of all orders for the correct patient, [1][2][3][4] the large number of orders placed by practitioners each day suggests that even an error rate of less than 1 in 1000 orders would still lead to approximately 600 000 orders placed for the wrong patient annually in the US. 4 Wrong-patient order entry occurs more frequently in the emergency department (ED), with its rate estimated to be up to 2 per 1000 orders. 2 This increased error rate may be attributable to the often crowded and fast-paced environment of the ED, where ED practitioners frequently multitask by caring for several patients at once with frequent interruptions midtask, including requests to place an order for a different patient.…”

A Comparison of One- and Four-Open-Chart Access: No Change in Computerized Provider Order Entry Error Rates

“…The reorder time of 10 minutes was chosen to parallel the "wrong-patient retract-and-reorder" methodology used in two randomized clinical trials, validated to indicate an order truly placed in error 76.2% of the time. 6,10 Using our vendor's native application, two separate queries of the EHR database were performed. The first query (Query 1) identified all orders placed by ED, HM, and MCH providers for each 2-week phase.…”

Limiting the number of open charts does not impact wrong patient order entry in the emergency department

“…20 found no difference in error rates when the number of open charts was restricted to 2 from 4. Likewise, Adelman et al21 also found no difference in error rates in their randomized study throughout a health system. In this study, the restricted group could only have 1 chart open at a time, and the unrestricted group could have up to 4 charts open, although ultimately 66% of the unrestricted group had only 1 chart open when they placed orders.These results suggest that the uniqueness of the high-stress ED environment and the number of charts open have no impact on the genesis of such errors.…”