Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
Healthcare Consulting Services with a Focus on Patient Safety Solutions and Quality Improvement Across the Health Care Continuum. Your Patient Safety Resource Solution.
May 21, 2019
Mixed Message on Number of Open EMR Records
Over 10 years ago, when we were doing our first electronic medical record (EMR) implementation, we predicted that wrong patient errors would likely increase as EMR adoption became more widespread (see our May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”). One of the reasons we identified was the ability to have the record of more than one patient open simultaneously. Back then, the major problem was that multiple IT systems were not yet integrated. So, it was possible to have one patient record open on a CPOE system and that of another open in a separate lab IT system or radiology PACS system. But, even as EMR’s became more integrated, some systems allowed users to have open records of more than one patient at a time.
The Joint Commission (TJC 2015) and the Office of the National Coordinator for Health Information Technology (ONC 2016) have agreed with us and recommended that the number of open EMR records be restricted to one record.
A recent study by Adelman and colleagues, whose work we have referenced in so many of our columns, has challenged that concept. The researchers (Adelman 2019) took advantage of a rollout of a new EMR to randomize users to being restricted to one open record at a time vs being allowed to have as many as four records open simultaneously. They then used their RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify instances where a user initially entered an order on the wrong patient. The RAR methodology is also nicely described in the supplement to the current Adelman study. It is a tool we’ve recommended you use in tracking and monitoring patient misidentification issues as part of your quality improvement program (see our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification”). The RAR methodology, of course, measures near misses (by definition, it identifies instances where the user recognized the error and corrected it). But it is one of the only proxies we have for assessing the frequency of potential wrong-patient ordering errors.
Overall, there was no significant difference in wrong-patient order sessions per 100,000 in the restricted vs unrestricted group, or in any setting. However, in the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, thereby limiting the power of the study to detect a treatment effect. Furthermore, when they did a post hoc analysis of order sessions in the unrestricted group, the number of wrong-patient order sessions completed with 1 record open was 52.0 per 100,000 order sessions, 132.0 per 100,000 with 2 records open, 165.7 per 100,000 with 3 records open, and 184.5 per 100,000 with 4 records open. Those results were also statistically significant.
The authors conclude that 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. But they note that, since clinicians in the unrestricted group placed most orders with a single record open, 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 was limited.
In the accompanying editorial (Wachter 2019), Wachter et al. note there are confounders in this issue. One is that circumstances in which a user might want more than one record open are also ones that might engender errors. In complex healthcare environments workload and multitasking may be more important factors contributing to errors. They also remind us that we need to consider unintended consequences and look at the whole picture. An example they give is someone entering a complex heparin titration order who is interrupted for an urgent need for an analgesic on another patient. Closing one record, opening another, then reopening the first record could lead to errors that are not wrong-patient errors. Such tradeoffs between safety and efficiency have been a topic of many of our columns (see, for example, our Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs”).
Both the Adelman researchers and the editorialists seem reassured that the trial had sufficient power to test the primary question of whether a restricted vs unrestricted configuration reduces wrong-patient orders and that the less restrictive approach (allowing multiple records to be open simultaneously) does not lead to an overall increase in wrong-patient orders.
We don’t agree. Most of the points made in the editorial are ones we do agree with and have often discussed in our columns. But the major problem with the Adelman study is akin to the argument we’ve made in the overlapping surgery debate: the sheer size of the data buries the important findings. The sheer volume of instances where only one record was open dilutes out the findings that occurred when multiple records were open. It is hard to ignore the post-hoc analysis that has what we consider to be the most important facet of this study. It clearly shows that there is an increase in wrong-patient orders when multiple records are open simultaneously and this phenomenon occurs in a dose-dependent fashion.
We hope the study does not open the door to widespread adoption of the less restrictive policy. And, if healthcare systems do start to allow multiple records to be open at the same time, they should incorporate the RAR methodology as part of their quality improvement activities to monitor and track for patient misidentification errors.
We hope you’ll go back to our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” to review the multitude of issues related to wrong-patient events and what you should be doing to reduce the risks of such events in your organizations.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order ErrorsA Randomized Clinical Trial. JAMA 2019; 321(18): 1780-1787
https://jamanetwork.com/journals/jama/fullarticle/2733207
TJC (The Joint Commission). Safe use of health information technology. Sentinel Event Alert. Issue 54. March 31, 2015
https://www.jointcommission.org/assets/1/18/SEA_54.pdf
ONC (Office of the National Coordinator for Health Information Technology). Self-assessment: patient identification: general instructions for the SAFER Self-Assessment Guides. September 2016
https://www.healthit.gov/sites/default/files/safer/guides/safer_patient_identification.pdf
Wachter RM, Murray SG, Adler-Milstein J. Restricting the Number of Open Patient Records in the Electronic Health Record. Is the Record Half Open or Half Closed? JAMA 2019; 321(18): 1771-1773
https://jamanetwork.com/journals/jama/article-abstract/2733189
Print “Mixed Message on Number of Open EMR Records”
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
If you don't see the search term you expected to see here, its probably because that tip already went to our Tip of the Week Archive. We do a new tip every week. Click here to search the entire site or you can Go to Tip of the Week Archive a patient safety resource solution loaded with tips, tools, and techniques you can use in your patient safety and quality improvement initiatives. Or it may have moved to our What's New Archive.
Click here to see the consulting services and patient safety solutions that we provide.
Click on the "Contact Us" button at the left to send us your comments on our "What's New in the Patient Safety World" columns.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
May2019
We’re, of course, big fans of the use of checklists in healthcare. We’ve done several columns on the successes of the WHO Surgical Safety Checklist. Our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist” described the tool and provided the link to download the checklist tool and instructions how to use it. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.
In our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” we discussed the striking improvements in patient outcomes following implementation of the WHO Surgical Safety Checklist at hospitals in eight different countries. Haynes and colleagues (Haynes 2009) demonstrated that mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. That’s a relative risk reduction of approximately 36% for mortality and major morbidity!
But, in our April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we noted a study that showed, despite widespread adoption in over 100 hospitals in Ontario, Canada, a surgical checklist failed to demonstrate significant reductions in adjusted rates for mortality or complications (Urbach 2014). The rate of any complication decreased from 3.86% to 3.82% and mortality at 30-days post-op decreased from 0.71% to 0.65% in Canadian study, neither being statistically significant. There was also no significant changes in rates of hospital readmission and emergency department visits within 30 days after discharge. This result was surprising, especially since self-reported compliance with the checklist was over 90% at almost all participating hospitals. We discussed some of the reasons that study may have failed to demonstrate significant improvement after implementation of the checklist.
But in that April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we also noted several other examples where the WHO Surgical Safety Checklist or similar checklists have led to substantial improvements in perioperative outcomes. We also noted other studies demonstrating improvements after implementation of the Surgical Safety Checklist in our What's New in the Patient Safety World columns for May 2015 “The Great Checklist Debate” and May 2017 “Another Success for the Safe Surgery Checklist”.
Now another study from Scotland (Ramsay 2019) showed that implementation of the WHO Surgical Safety Checklist produced striking improvement in mortality. The WHO Surgical Safety Checklist was implemented in Scotland as part of a broader patient safety initiative between 2008 and 2010, Analyzing almost 7 million surgical cases between 2000 and 2014, the researchers found a 37% reduction in mortality. There was no such improvement trend for non-surgical cases over the same timeframe. While some improvement may have been related to other factors, the authors attribute the striking success to adoption of the WHO Surgical Safety Checklist.
Of course, implementing a checklist does not guarantee that it will be fully adhered to. In commenting a Norwegian study (Haugen 2015), several of the coauthors of the original WHO study pointed out that the Norwegian study showed a “dose effect” in that larger reductions in complications were seen when all portions of the checklist were followed (Haynes 2015).
We hope you’ll look at some of the recommendations about how to implement checklists in our November 20, 2018 Patient Safety Tip of the Week “Checklist Implementation” and our many prior columns on checklists listed below.
Some of our prior columns on checklists:
References:
WHO Surgical Safety Checklist
http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf
Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-499
http://www.nejm.org/doi/full/10.1056/NEJMsa0810119#t=articleTop
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029-1038
http://www.nejm.org/doi/full/10.1056/NEJMsa1308261
Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. British Journal of Surgery 2019; Early access 16 April 2019
https://onlinelibrary.wiley.com/doi/10.1002/bjs.11151
Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 2015; 261(5): 821-828
Haynes AB, Berry WR, Gawande AA. What Do We Know About the Safe Surgery Checklist Now? Annals of Surgery 2015; 261(5): 829-830
Print “May 2019 WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”
Every year ECRI Institute publishes its list of the “Top 10 Patient Safety Concerns for Healthcare Organizations”.
This year’s ECRI Top 10 list (ECRI 2019):
1. Diagnostic Stewardship and Test Result Management Using EHRs
2. Antimicrobial Stewardship in Physician Practices and Aging Services
3. Burnout and Its Impact on Patient Safety
4. Patient Safety Concerns Involving Mobile Health
5. Reducing Discomfort with Behavioral Health
6. Detecting Changes in a Patient’s Condition
7. Developing and Maintaining Skills
8. Early Recognition of Sepsis across the Continuum
9. Infections from Peripherally Inserted IV Lines
10. Standardizing Safety Efforts across Large Health Systems
We’ve covered most of these topics in numerous columns. As usual, we’ll only comment on a few of this year’s topics and let you go to the ECRI document for details of these and all the others.
ECRI’s #1 would also be our #1. It deals with ensuring that we have systems in place to follow up on all diagnostic studies and ways to communicate results to all appropriate parties. While it focuses on using EHR’s for this purpose, it clearly notes the importance of using all forms of communication to ensure “closing the loop”.
New to this year’s list is #9 “Infections from Peripherally Inserted IV Lines”. So add infection risk to the complications of peripheral IV’s we discussed in our February 26, 2019 Patient Safety Tip of the Week “Vascular Access Device Dislodgements”.
The ECRI report also has links to ECRI’s many fine resources for each topic. We’ll let you go to the full ECRI list for details. Click here to go to the ECRI Institute site where you can download the list. And see the links to our many columns on “closing the loop” listed below.
See also our other columns on communicating significant results:
References:
ECRI Institute. Top 10 Patient Safety Concerns for 2019. ECRI Institute 2019
https://www.ecri.org/landing-top-10-patient-safety-concerns-2019
Print “May 2019 ECRI 2019 Top 10 Patient Safety Concerns”
Our April 2017 What's New in the Patient Safety World column “How Much Time Do We Actually Spend on the EMR?” discussed numerous studies documenting how much time various healthcare professionals are spending on electronic medical records, often at the expense of time directly interacting with patients.
Now a recent observational study of interns (Chaiyachati 2019) found that they spent a mean of 15.9 hours of a 24-hour period (66%) in indirect patient care, mostly interactions with the patient’s medical record or documentation. A mean of only 3.0 hours was spent in direct patient care (13%) and 1.8 hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred frequently. The study confirms that interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. It serves as a wakeup call that we need to investigate ways to better balance our time between direct and indirect patient care.
Our April 2017 What's New in the Patient Safety World column “How Much Time Do We Actually Spend on the EMR?” noted some studies showing how use of scribes or other forms of dictation support may lead to freeing up more time for direct patient care. But is also again raised a concern that we may neglect import elements of the EMR. In our March 22, 2011 Patient Safety Tip of the Week “An EMR Feature Detrimental to Teamwork and Patient Safety” we noted a study that had very bothersome results. Hripcsak and colleagues (Hripcsak 2011) analyzed time spent authoring notes and time spent reading notes in the EMR. They found most users spent 90 minutes a day authoring notes, 30 minutes a day reading notes. But the bothersome feature was a striking disparity in the rates of notes read that were authored by various healthcare workers. They found 97% of attending notes were read by someone and 99% of resident notes were read by someone. But fewer than 20% of nurses’ notes were read by attendings or residents! And only 38% of nurse’s notes were read by other nurses. 16% of all notes were never read by anyone!
Electronic medical records bring great opportunities to improve patient care but, in their current state of the art, have a tendency to intrude on workflows and detract from face-to-face interaction with our patients.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Chaiyachati KH, Shea JA, Asch DA, et al. Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations. JAMA Intern Med 2019; Published online April 15, 2019
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2730353
Print “May 2019 Too Much Time on the EMR”
Prophylactic antibiotics are important for reducing the risk of surgical site infections (SSI’s) for many surgical procedures. We know from previous studies that benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Hence, guidelines and patient safety initiatives have been focused not only on the timing of administration of prophylactic antibiotics, but also on ensuring that such are promptly discontinued following surgical procedures.
Most national guidelines and quality measures state that surgical antimicrobial prophylaxis be initiated <1 hour prior to surgery and discontinued <24 hours post-operatively, and <48 hours for cardiac surgery. Notably, several surgical societies have noted lack of evidence that continuing prophylactic antibiotics after wound closure reduces SSI’s and thus recommend cessation of prophylactic antibiotics at the time the wound has been closed, with certain exceptions (Ban 2017).
A new study focused on the harms of longer duration of exposure to such prophylactic antibiotics (Branch-Elliman 2019). The study looked at patients who underwent cardiac, orthopedic total joint replacement, colorectal, and vascular procedures within the national Veterans Affairs health care system. The researchers separated duration of postoperative antimicrobial prophylaxis into the following categories: <24 hours, 24-<48 hours, 48-<72 hours, and ≥72 hours. They found that increasing duration of antimicrobial prophylaxis was associated with higher odds of acute kidney injury (AKI) and C difficile infection in a duration-dependent fashion. Extended duration did not lead to additional SSI reduction.
Number needed to harm (NNH) is a concept that puts the issue in a perspective that often emphasizes the size effect of an intervention. The researchers found that the NNH for AKI after 24 to less than 48 hours, 48 to less than 72 hours, and 72 hours or more of postoperative prophylaxis were 9, 6, and 4, respectively. For C difficile infection the NNH were 2000, 90, and 50, respectively.
These results reinforce that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI.
References:
Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Amer Coll Surg 2017; 224(1): 59-74
https://www.journalacs.org/article/S1072-7515(16)31563-0/fulltext
Branch-Elliman W, O’Brien W, Strymish J, et al. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg 2019; Published online April 24, 201
https://jamanetwork.com/journals/jamasurgery/fullarticle/2731307
Print “May 2019 Focus on Prophylactic Antibiotic Duration”
Print “May 2019 What's New in the Patient Safety World (full column)”
Print “May 2019 WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”
Print “May 2019 ECRI 2019 Top 10 Patient Safety Concerns”
Print “May 2019 Too Much Time on the EMR”
Print “May 2019 Focus on Prophylactic Antibiotic Duration”
Go to the "Whats New Archive"
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax