Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial

Jason S. Adelman, Jo R. Applebaum, Clyde B. Schechter, Matthew A. Berger, Stan H. Reissman, Raja Thota, Andrew D. Racine, David K. Vawdrey, Robert A. Green, Hojjat Salmasian, Gordon D. Schiff, Adam Wright, Adam Landman, David W. Bates, Ross Koppel, William L. Galanter, Bruce L. Lambert, Susan Paparella, William N. Southern

Research output: Contribution to journalArticle

9 Scopus citations

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 12140298 orders, in 4486631 order sessions, placed for 543490 patients. There was no significant difference in wrong-patient order sessions per 100000 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.

Original languageEnglish (US)
Pages (from-to)1780-1787
Number of pages8
JournalJAMA - Journal of the American Medical Association
Volume321
Issue number18
DOIs
StatePublished - May 14 2019

ASJC Scopus subject areas

  • Medicine(all)

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    Adelman, J. S., Applebaum, J. R., Schechter, C. B., Berger, M. A., Reissman, S. H., Thota, R., Racine, A. D., Vawdrey, D. K., Green, R. A., Salmasian, H., Schiff, G. D., Wright, A., Landman, A., Bates, D. W., Koppel, R., Galanter, W. L., Lambert, B. L., Paparella, S., & Southern, W. N. (2019). Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial. JAMA - Journal of the American Medical Association, 321(18), 1780-1787. https://doi.org/10.1001/jama.2019.3698