The mouse slips, and the emergency room doctor clicks on the wrong number, ordering a medication dosage that's far too large. Elsewhere, in another ER's electronic health record, a patient's name isn't clearly displayed, so the nurse misses it and enters symptoms in the wrong person's file.
As ER doctors and nurses grapple with the transition to digitized record systems, these mistakes seem to be happening more frequently. “There are new categories of patient safety errors” in emergency rooms that didn't exist before the push to use electronic record systems, said Raj Ratwani, scientific director at MedStar Health's National Center for Human Factors in Healthcare in Washington, D.C.
One of the major promises of the 2009 federal stimulus program that provided financial incentives to hospitals that adopted EHRs was a reduction in errors as they linked physician and hospital patient records. But in ERs, where things often happen fast, the push for interoperability sometimes sets up a technology mismatch that creates challenges that aren't necessarily as evident in other parts of the hospital.
Doctors and nurses rush between patients, often juggling multiple cases. Verbal communication is key. Patients can wait in a triage room for extended periods until a free nurse or physician arrives to find out what's wrong.
To service this chaotic environment, many hospitals initially created EHRs that were independent of hospital-wide systems. Since those homegrown ER systems often aren't compatible with the newer, comprehensive ones hospitals are buying, they're being phased out.
But the newer EHR models often require adjustments to meet ER needs. “The way the systems are set up, it can actually predispose to higher error rates,” said Dr. Jesse Pines, who directs the Office for Clinical Practice Innovation at the George Washington University School of Medicine in Washington.
In 2013, Pines and other members of the American College of Emergency Physicians wrote a report that found mistakes in the ER—like ordering the wrong medications or, because of confusing computer displays, missing key patient information—were common after the switch to a new digital system. The report suggested many of the mistakes might be the result of poor design rather than user error. “It's certainly a patient safety concern,” said Dr. Jason Shapiro, an associate professor of emergency medicine at Mount Sinai Hospital in New York, who co-authored the report.
There's no research measuring how often these errors—like entering care instructions in the wrong patient file or missing instructions altogether—cause actual harm. “We've got to figure out how we're working with our electronic records, to make it part of the workflow,” said Dr. Nathan Spell, chief quality officer at Emory Hospital in Atlanta. Even when doctors have learned how to use the record systems, missteps still occur.