Healthcare News & Insights

Keep ED patients safe: Common information system errors

ThinkstockPhotos-185509324Emergency department information systems (EDIS) provide much-needed help, such as legible documentation, retrieval of past patient information and adherence to best practices. But just like with anything else, with the positives come the negatives. 

For EDISs the big negative would be contributing to medical errors.

The key to avoiding this negative and keeping your hospital out of hot water is knowing what to look for. To help you out, here are four clinical scenarios from the Annuals of Emergency Medicine in which EDISs can contribute to medical errors that put your patients at risk.

1. Communication failures

SCENARIO:
An ED physician sees a patient moaning and clutching his right side. A nurse tells the doctor the patient thinks it’s his kidney stones. The physician examines the patient and orders 1mg of hydromorphone to help relieve some of the pain. Then the physician is pulled away to reevaluate a patient who is critical.

After taking care of that patient, the physician finally gets time to chart and enter orders on the system for the alleged kidney stone patient. When he goes back and checks on that patient, he is difficult to wake. The doctor then questions the nurse as to what she gave the patient. The nurse explains that she gave the 1mg of hydromorphone after they spoke in the patient’s room, then she gave another 1mg of the same drug as per the physician computerized order entry with an as-needed order for a third.

So how did this mix up occur?

The nurse gave the patient the first 1mg of hydromorphone when the doctor verbally ordered it in the patient’s room. Then she sees a second order via the computer some time later. What she doesn’t know is the doctor saw a critical patient in between seeing the kidney stone patient and entering that patient’s orders. So in her mind this was a second order for the 1 mg hydromorphone with an as needed third dose. But to the doctor he was just entering the first order of 1 mg hydromorphone with an as needed for a second 1 mg.

It was a simple miscommunication.

2. Poor data display

SCENARIO:
It’s late at night and the ED has been swamped with patients for over 24 hours with no relief in sight. An ED doctor has more than 27 patients. While a bunch of the patients have labs and/or imaging results pending for review, the doctor is still waiting on a few results for the sickest patients.

The doctor quickly scans the pending results and clicks “accept all,” which places the results into patients’ individual charts. But the doctor misses an elevated troponin level for a cardiac patient. Luckily the lab calls and alerts the doctor, who then has the patient re-evaluated and orders an ECG, which shows evolving ST changes. Thanks to this the patient is whisked off to the catheterization lab directly from the ED.

One complaint about many EDISs is poor data display. Simply listing the results in tabular or text format, as most do, makes it easy to miss an abnormal test result. And despite abnormal results often being bolded, noted in red or underlined, it’s still difficult to catch when doctors are in a hurry, tired and scanning results.

Since results aren’t manually transcribed any more, it’s easy for potentially harmful oversights to be made.

3. Wrong patient error

SCENARIO:
As with most EDs it’s a typical busy night. A doctor is taking care of a 34-year-old man who is suffering withdrawal from alcohol and is extremely agitated. She just sits down at the computer and opens the patient tracker so she can order 2 mg of intravenous lorazepam for the patient when she’s interrupted to sign an ECG for an elderly man with chest pains who just arrived by ambulance. 

Concerned about a possible myocardial infarction, the doctor quickly orders the lorazepam and rushes to the chest pain patient. Problem is, the doctor didn’t realize she wasn’t on the correct patient and instead orders the lorazepam for another one of her patients – an 80-year-old with congestive heart failure. Due to the mistake, the 80-year-old woman nearly goes into respiratory arrest and has to be intubated.

True, this type of “wrong order, wrong patient” error can happen with paper-based systems. However, anecdotal reporting has revealed an alarming number of physicians admitting to a substantial increase in the number of errors while using the computerized physician order entry components of information systems.

4. Alert fatigue

SCENARIO:
A nursing home patient is septic with pneumonia, the doctor wants to order a fluid bolus and antibiotics to administer immediately, but the EDIS keeps telling him, “Warning! There is no weight on file for this patient. Enter a reason you wish to proceed with 1,000 mL normal saline solution.” Then the system says, “Warning! The patient has a documented allergy to penicillin. You must enter a reason why you wish to proceed with your order of cefepime.” So instead, the doctor orders vancomysin and again the computer says, “Warning! The patient has an adverse reaction to vancomycin. You must enter a reason why you wish to proceed with your order of vancomycin.”

Frustrated, the physician bypasses the pop up and orders the antibiotic anyway. An hour later, a nurse turns off the vancomycin infusion, asks the doctor to order diphrenhydramine, and files an incident report about a preventable adverse medication reaction.

One study showed 250,000 prescription alerts during a six-month period prevented 402 adverse drug events — 49 of which were deemed serious and three were deemed fatal. However, in the study, over 90% of those alerts were overridden. So only 10% accounted for adverse drug event preventions.

Another study showed that even high-severity alerts only were accepted 25% to 45% of the time, and the worst high-severity alerts were accepted 2% to 8% of the time.

It would seem by these statistics that while alerts are a good thing, a bombardment of alerts does produce alert fatigue.

Recommendations

The Annuals of Emergency Medicine suggests the following as ways to improve the safety of EDISs:

  • An ED clinician should lead and maintain a performance improvement process for the EDIS
  • A multidisciplinary EDIS performance improvement group should be created and meet on a regular basis
  • A review process of EDIS safety issues should be created and monitored closely
  • Any concern raised by the group should be addressed in a timely manner
  • Lessons learned from by the group should be shared, and
  • “Hold harmless” or “learned intermediary” clauses should be removed from vendor software contracts.

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