"Half an hour later, you check in on the patient and he is difficult to arouse. 'How many milligrams of hydromorphone did the patient get?' you inquire. The nurse tells you 3 doses of 1 mg each. 'How did that happen?'
"Well, you remember you asked me to give 1 mg of hydromorphone while we spoke in the room, then you ordered another 1 mg in computerized physician order entry with an as needed order for a third."
2. Poor data display
The report says most vendor products list the results in tabular or text format, requiring the physician "to scroll through long tables or lists of results." While some abnormal results are often in bold, in red, or underlined, it's tough for the clinician to distinguish the truly abnormal results from those that are less important.
"It's 10:30 p.m., admitted patients have been stacking up in the ED since the day before, and there is no relief in sight from the crowding. You have 27 patients in your section of the ED, and more than half have results pending from various imaging and laboratory studies. You are waiting for a few critical laboratory values on your sickest patients, and you are scrolling through the "Results" section on the new EDIS.
"You try to review laboratory results for many of your patients quickly and click a button to "accept all" results, which enters the results into individual patient charts. In doing so, you miss an elevated troponin level for a patient who was admitted for a cardiac evaluation."