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JMIR Hum Factors. 2018 Feb 6;5(1):e4. doi: 10.2196/humanfactors.9371.

Reducing Misses and Near Misses Related to Multitasking on the Electronic Health Record: Observational Study and Qualitative Analysis.

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Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.
University of California, San Francisco Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, United States.
Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.



Clinicians' use of electronic health record (EHR) systems while multitasking may increase the risk of making errors, but silent EHR system use may lower patient satisfaction. Delaying EHR system use until after patient visits may increase clinicians' EHR workload, stress, and burnout.


We aimed to describe the perspectives of clinicians, educators, administrators, and researchers about misses and near misses that they felt were related to clinician multitasking while using EHR systems.


This observational study was a thematic analysis of perspectives elicited from 63 continuing medical education (CME) participants during 2 workshops and 1 interactive lecture about challenges and strategies for relationship-centered communication during clinician EHR system use. The workshop elicited reflection about memorable times when multitasking EHR use was associated with "misses" (errors that were not caught at the time) or "near misses" (mistakes that were caught before leading to errors). We conducted qualitative analysis using an editing analysis style to identify codes and then select representative themes and quotes.


All workshop participants shared stories of misses or near misses in EHR system ordering and documentation or patient-clinician communication, wondering about "misses we don't even know about." Risk factors included the computer's position, EHR system usability, note content and style, information overload, problematic workflows, systems issues, and provider and patient communication behaviors and expectations. Strategies to reduce multitasking EHR system misses included clinician transparency when needing silent EHR system use (eg, for prescribing), narrating EHR system use, patient activation during EHR system use, adapting visit organization and workflow, improving EHR system design, and improving team support and systems.


CME participants shared numerous stories of errors and near misses in EHR tasks and communication that they felt related to EHR multitasking. However, they brainstormed diverse strategies for using EHR systems safely while preserving patient relationships.


electronic health records; patient safety; physician-patient relations

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