Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, Informatics

Health Policy Journal Club: Sacrificing Efficiency for Safety

Does limiting the number of open charts in an electronic medical record reduce medical error? Survey says... no.

Perhaps no other specialty in medicine deals with constant task-switching as much as emergency medicine. It happens frequently during a shift: you are in the middle of one task and get interrupted to place an order for a different patient. There is a certain cognitive load to keeping your current task in mind, while switching charts in your electronic medical record (EMR) system. You see a message that you are not able to open another chart, you must close an open chart first; this inevitably causes frustration. A major reason for the limitation in the number of open charts is to minimize orders being accidentally placed for the wrong patient, an argument that superficially makes sense. However, limiting the number of open charts does not limit the number of patients being cared for at the same time.

A new study sought to establish whether a lower limit of open charts in the EMR led to a reduction in accidental orders being placed for the wrong patient. They performed a retrospective chart review at 13 emergency departments where they counted retract and reorder events, which were defined as a procedure or medication order that was placed, retracted, and reā€entered on a different patient within 10 minutes. While limited, this simple approach can be expected to catch a number of mistaken entry errors. The researchers evaluated two periods of evaluation with limits of either 2 or 4 open charts.

Their findings showed retraction rates of 2.4 per thousand when 4 charts could be opened versus 2.2 per thousand when only up to 2 charts could be simultaneously opened. Ultimately, there was no statistically significant difference in the rates of retract-and-reorder events, the chosen proxy for these near-miss medical errors.

While this study is not sufficiently rigorous to conclude with certainty that limiting concurrently open charts does not reduce error rates, it provides some evidence that runs opposite to recommendations offered by the Joint Commission to limit open charts to only one. In my opinion, the loss of efficiency with fewer open charts without a verifiable increase in patient safety does neither the doctor nor the patient any good.

Abstract: Canfield C, Udeh C, Blonsky H, Hamilton AC, Fertel BS. Limiting the number of open charts does not impact wrong patient order entry in the emergency department. J Am Coll Emerg Physicians Open. 2020;1(5):1071-1077.

Objective: We sought to examine the impact of limiting the number of open active charts on wrong patient order entry events among 13 emergency departments (EDs) in a large integrated health system.

Methods: A retrospective chart review of all orders placed between September 2017 and September 2019 was conducted. The rate of retract-and-reorder events was analyzed with no overlap in both the period pre- and post-intervention period. Secondary analysis of error rate by clinician type, clinician patient load, and time of day was performed.

Results: The order retraction rate was not improved pre- and post-intervention. Retraction rates varied by clinician type, with residents retracting more often than attending physicians (odds ratio [OR] = 1.443 [1.349, 1.545]). Advanced practice providers also showed a slightly higher rate than physicians (OR = 1.114 [1.071, 1.160]). Pharmacists showed very low rates compared to physicians (OR = 0.191 [0.048, 0.764]). Time of day and staffing ratios appear to be a factor, with wrong patient order entry rates slightly lower during the night (1900-0700) than the day (OR 0.958 [0.923, 0.995]), and increasing slightly with every additional patient per provider (OR 1.019 [1.005, 1.032]). The academic medical center had more retractions than the other EDs. OR for the various ED types compared to the Academic Medical Center included Community (OR 0.908 [0.859, 0.959]), Teaching Hospitals (OR 0.850 [0.802, 0.900]), and Freestanding (OR 0.932 [0.864, 1.006]).

Conclusions: Limiting the number of open active charts from 4 to 2 did not significantly reduce the incidence of wrong-patient order entry. Further investigation into other factors contributing to order entry errors is warranted.

PMID: 33145560

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.