Having Multiple Electronic Health Records Open Simultaneously May Not Increase Wrong-Patient Order Errors

Restricting clinicians to having one electronic health record (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, according to a new AHRQ study on clinician use of EHRs. In the study, published in the May JAMA Network, researchers compared the risk of wrong-patient orders while accessing one versus four EHRs open in a variety of clinical settings, including hospitals, emergency departments 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. Access the abstract. An accompanying editorial takes a closer look at the study

2019 May 14;321(18):1780-1787. doi: 10.1001/jama.2019.3698.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

Adelman JS1,2,3, Applebaum JR2, Schechter CB4, Berger MA5, Reissman SH6, Thota R6, Racine AD7, Vawdrey DK2,3, Green RA2,3, Salmasian H8, Schiff GD9, Wright A10, Landman A11, Bates DW10,12, Koppel R13,14, Galanter WL15, Lambert BL16, Paparella S17, Southern WN18.

Author information

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]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

CONCLUSIONS AND RELEVANCE:

A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.