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JAMA. 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.

Author information

1
Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York.
2
Departmentof Quality and Patient Safety, NewYork-Presbyterian Hospital, New York.
3
Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York.
4
Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York.
5
Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.
6
Montefiore Health System, Bronx, New York.
7
Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.
8
Division of Internal Medicine, Department of Medicine, Harvard Medical School, and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts.
9
Primary Care Center, Harvard Medical School, Department of Medicine, Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
10
Division of General Internal Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
11
Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
12
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, and Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts.
13
Departments of Sociology and Biomedical Informatics, University of Pennsylvania, Philadelphia.
14
Department of Biomedical Informatics, University at Buffalo (SUNY), Buffalo, New York.
15
Department of Medicine, Division of Academic Medicine and Geriatrics, and Departments of Pharmacy Practice and Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago.
16
Department of Communication Studies, Center for Communication and Health, Northwestern University, Evanston, Illinois.
17
Institute for Safe Medication Practices, Horsham, Pennsylvania.
18
Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.

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.

Trial Registration:

clinicaltrials.gov Identifier: NCT02876588.

PMID:
31087021
PMCID:
PMC6518341
[Available on 2019-11-14]
DOI:
10.1001/jama.2019.3698
[Indexed for MEDLINE]

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