Electronic records in the ER: A breeding ground for error

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.

The ER's culture and pace can amplify the risks of human error when the EHR is less than user-friendly. Think of the emergency physician who, reaching the end of a hectic 12-hour shift, looks for the record of a patient he just examined. He types in the man's last name, clicks and writes medical instructions—not realizing that he has pulled up the file of another patient with the same last name and similar age.

While misidentifying patients in this way wasn't much of an issue before EHRs, it's “becoming quite prevalent,” in this more digital era, Ratwani said.

Many systems, meanwhile, allow doctors to edit the medical record for only one patient at a time, said Dr. Zach Hettinger, who practices emergency medicine at MedStar Union Memorial Hospital in Baltimore. That makes it harder to keep track of things, he said. “You're stuck with, 'Do I cancel what I'm in the middle of and not complete that task? Or do I deal with the new task? Do I make a note somewhere—take scrap paper—or just remember it?' ” said Hettinger, who is medical director of the National Center for Human Factors in Healthcare.

How does that scenario play out? A triage nurse who is attending to multiple patients at once might scribble each individual's details on the back of a piece of paper—ducking away later to enter the information into the computer system. That can make it easier to confuse patient records, and leave the ER short a nurse.

To be sure, electronic records have resolved many safety concerns, Pines said. They've rendered obsolete issues like misreading doctors' handwriting. And accessing records is easier and faster, noted Dr. Dan Hampton, an emergency physician who works at Epic Systems Corp., a major electronic health-record vendor.

But because doctors don't decide what a hospital buys, EHR designs often emphasize what administrators or technology officials want, Pines said. To understand ERs, designers must spend time in them, said Dr. Shawna Perry, an associate professor of emergency medicine at the University of Florida Medical College at Jacksonville.

“It's one thing to have a computer and informaticists on your staff, or to have a doctor come in and look at this” particular design feature, said Dr. Robert Wachter, a patient safety expert at the University of California at San Francisco. “It doesn't get into this issue of what does it look like to be using this system at 4 in the morning, when you have nine other patients and a trauma patient running into the ER, and your beeper's going.”

Manufacturers have said doctor feedback is prioritized in their designs. Epic sends developers to hospitals to study their needs. At Cerner Corp., doctors on advisory councils give feedback on ER-specific health record systems. Cerner representatives visit ERs to hear from physicians, said Leslie Lindsey, Cerner's senior manager of emergency medicine.

There's room to improve, Lindsey said. To address oral communication, Cerner sells supplements, such as a phone-like device meant to fix communication gaps with emergency medicine. But hospitals may not want to buy add-ons when they've already paid tens or even hundreds of millions of dollars for an EHR system.

Even critics think EHR companies will address kinks in ER software over time. “Think about where we were even 30 years ago with cars. Cars are rapidly innovating to become safer and more efficient,” Pines said. “We can expect to see the same transformation in the electronic health-record space.”

This article was produced by Kaiser Health News, a health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.