EHR Design Flaws Contribute to Patient Harm in the ED
3. Wrong order/wrong patient error
"You are caring for several patients and have just left the room of an agitated 34-year-old woman who is withdrawing from alcohol. You go to your computer, open the patient tracker, and intend to order 2 mg of intravenous lorazepam for the patient. While in the process of preparing to enter the order, you are interrupted to 'sign' an ECG of a 65-year-old man with chest pain who has just arrived by ambulance.
"You are concerned about a possible ST-segment elevation myocardial infarction, so you hurriedly enter the order for lorazepam and proceed to go
to the room of the chest pain patient. The lorazepam order is inadvertently entered on another patient, an 80-year-old with congestive heart failure, who is also one of your current patients and whose name is listed on the EDIS tracker. The patient has a near respiratory arrest and needs to be intubated."
The report adds that although such errors happen with paper-based systems, "an alarming number of clinicians are anecdotally reporting a substantial increase in the incidence of wrong order-wrong patient errors while using computerized physician order entry components of information systems."
It adds that "there are few consistent data on how commonly these errors occur, and few studies are actually focused on collecting evidence of these errors."
4. Alert fatigue
The volume of frequent alerts and warnings "can dull the senses, leading to a failure to react to a truly important warning," the report says. Unfortunately, the panel says, "the effect of alert fatigue on clinical decision support and computerized physician order entry has largely focused on patient care outside the ED" though it happens all too often inside the ED as well.
" 'Warning! The patient has a documented allergy to penicillin. You must enter a reason why you wish to proceed with your order of cefepime.'
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