“Just a Few Seconds of Your Time…” at Least 130 Million Times a Year

Abstract

On the heels of the Institute of Medicine's somewhat contested report on the safety of health information technology, 1,2 an international group of informatics experts warned that health care was entering a decade of danger. 3 They feared that the widespread deployment of health information technology systems that are "less mature than we would like" would exceed developers', managers', and clinicians' abilities to anticipate, understand, and cope with the potential consequences and so would lead to a substantial increase in the harms associated with health information technology until improvements in the quality of design, software, and implementation could catch up. In the meantime, I suspect that attempts to mitigate these risks will result in the decade of danger becoming known as the decade of the kludge.The Oxford English Dictionary traces the first published use of kludge to a 1962 satirical essay on computing that defined it as "an ill-assorted collection of poorly matching parts, forming a distressing whole." 4 It is widespread in the vernacular of computer science and engineering, where it is used to describe patching over a problem or bug in an inelegant manner without fundamentally resolving it.In this issue of Annals, Green et al 5 report an approach to wrong-patient orders in computerized provider order entry systems that would be fair to call a kludge. Although it is difficult to estimate the volume of wrong-patient orders in emergency departments (EDs), they are widely thought to have increased after the introduction of computerized provider order entry systems because of the loss of subtle cues of identity that had been part of the paper chart: physical placement, handwriting, length, differences in grammar, even coffee stains, etc. 6 Pham et al 7 reported that wrong-patient orders were 3-fold higher in EDs using computerized provider order entry compared with those using paper orders. Although many wrong-patient orders are intercepted before being carried out, and others may be inconsequential, the potential for devastating harm is obvious.The intervention by Green et al 5 involved displaying a patient verification dialogue screen that required active confirmation from the physician before moving on to the order placement screen. It was designed so that physicians could not "click ahead" in anticipation of the confirmation request by means of a 2.5-second delay before any input other than canceling the order session would be accepted. The design of the verification screen attempted to restore some of the subtle cues that paper charts afforded for distinguishing patients by displaying not only the name, age, and sex but also other attributes such as chief complaint, bed location, length of stay, and recent medication orders-all cues to help physicians form a more accurate picture of the chart they were actually working in, as opposed to the one they had intended to work in. This was a good design decision because users tend to respond to these sorts of prompts as if they were questions about inte...

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

“…Alerts can also include warnings about patients with similar names because this issue is associated with a higher risk of WPOE errors . However, these interruptive solutions risk slowing practitioners’ workflow, and multiple exposures to electronic alerts can reduce the practitioners’ engagement with the alerts, also known as alert fatigue . Therefore, noninterruptive solutions for enhancing patient identification and reducing wrong-patient errors, if effective, would be desirable and important.…”