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

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 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Adelman reported receiving grants from the Agency for Healthcare Research and Quality and the National Institute for Child Health and Human Development during the conduct of the study. Dr Schechter reported receiving grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr Landman reported receiving grants from CRICO Risk Management Foundation during the conduct of the study and personal fees from Abbott Medical Device Cybersecurity Council outside the submitted work. Dr Bates reported consulting for EarlySense, which makes patient safety monitoring systems. He receives cash compensation from CDI-Negev Ltd, which is a not-for-profit incubator for health information technology startups. He receives equity from ValeraHealth, which makes software to help patients with chronic diseases; from Clew, which makes software to support clinical decision-making in intensive care; and from MDClone, which produces deidentified versions of clinical data. Dr Bates’ financial interests have been reviewed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their institutional policies. Dr Galanter reported receiving personal fees from Columbia University during the conduct of the study. Dr Lambert reported owning a company that offers consulting and software services related to preventing medication errors and responding to unexpected medical harm. These companies had no involvement in or impact on the conduct or write-up of this study. No other disclosures were reported.

Figures

Figure 1.. Randomization and Assignment of Clinicians

The primary analysis included all orders placed by clinicians according to their assigned randomization group (as-randomized analysis). Of 3356 clinicians randomized, 400 were not assigned to the trial group to which they were randomized. Of these, 305 were assigned to the opposite group at the beginning of the trial and remained in that group throughout (185 from restricted to unrestricted, 120 from unrestricted to restricted); 95 switched groups during the trial (84 from restricted to unrestricted, 11 from unrestricted to restricted). All assessments were repeated per treatment received (as-treated analysis). a“Other” included nonclinical staff who were not authorized to place orders.

Figure 2.. Primary Results Comparing Wrong-Patient Order Sessions in the Restricted vs Unrestricted Group

aIn the restricted group, configuration limited to 1 record open at a time. bIn the unrestricted group, configuration allowed up to 4 records open concurrently. cRandom-effects logistic regression models were constructed, using the order session as the unit of analysis and the clinician as the random intercept. The order session, a series of orders placed consecutively by a single clinician for a single patient, represents an independent opportunity for an error to occur. Wrong-patient order sessions were defined as order sessions that included at least 1 wrong-patient Retract-and-Reorder event. The intervention effect did not differ among subgroups defined by practice setting; P for interaction = .99.