Pennsylvania Patient Safety Authority Examines Electronic Health Record (EHR) Errors Related to Default Values

The data analysis gives Pennsylvania healthcare facilities information they can use to avoid these types of errors when using EHRs Over 300 events related to EHR software defaults analyzed by the Pennsylvania Patient Safety Authority gives Pennsylvania healthcare facilities information they can use to avoid EHR events such as wrong-time and wrong-dose errors. The information was published in the September issue of the Pennsylvania Patient Safety Advisory released today.

"Default values are often used to add standardization and efficiency to hospital information systems," Erin Sparnon, MEng, patient safety analyst for the Pennsylvania Patient Safety Authority said.

"For example, a healthy patient using a pain medication after surgery would receive a certain medication, dose and delivery of the medication already preset by the healthcare facility within the EHR system for that type of surgery." The preset medication, dose and delivery are known as a default value.

Default values for time are often put into medication and lab orders to coordinate staff resources. Automated stop times are used to end drug orders after a certain amount of time unless a doctor or healthcare provider renews the order. However, EHR event reports show that patient harm can sometimes occur if these defaults are not used appropriately. Sparnon said of the 324 verified reports, 314 (97%) were reported as "event, no harm" meaning an error did occur, but there was no harm to the patient. Six were reported as "unsafe conditions" that did not result in a harmful event.

Two reports involving temporary harm that required treatment or intervention involved accepting a default dose of muscle relaxant which was higher than the intended dose, and giving an extra dose of morphine by accepting a default administration time which was too soon after the patient's last dose. Sparnon added that two other reports involved temporary harm that required initial or prolonged hospitalization. In the first report, a patient's temperature spiked after a default stop time automatically cancelled an antibiotic.

In the second report, a patient's sodium levels kept rising because a default note to administer an ordered antidiuretic "per respiratory therapy" caused nurses not to administer the drug because they thought (incorrectly) respiratory therapy was doing so. The three most commonly reported error types were wrong-time errors (200), wrong-dose errors (71) and inappropriate use of an automated-stopping function (28).

"Many of these reports also showed a source of erroneous data and the three most commonly reported sources were failure to change a default value, user-entered values being overwritten by the system and failure to completely enter information which caused the system to insert information into blank parameters," Sparnon said. "There were also nine reports that showed a default value needed to be updated to match current clinical practice."

The Authority analysis gives healthcare providers insight into the types and sources of error identified with EHRs and considerations that should be made when using default values. "The analysis shows that healthcare providers should consider their use of default values in order sets particularly when considering how users see and enter time information, how they address errors related to situations in which default values have not kept up with changes in clinical practice and consider whether EHR software allows users to easily tell the difference between user-entered data and system-entered data," Sparnon added.

For more information about the EHR study related to default values, go to the September Pennsylvania Patient Safety Advisory article "Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values," on the Authority's website at www.patientsafetyauthority.org.

The Authority's 2013 September Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include: -- Oral Medications Inadvertently Given via the Intravenous Route: Inadvertent intravenous (IV) administration of oral medications, while rare, has contributed to serious patient harm as seen in reports submitted to the Authority and in clinical literature.

Authority analysts identified 20 reports of inadvertent IV administration of oral medications submitted to the Authority between June 2004 and December 2012. All of the events reached the patient, and 20 percent resulted in patient harm, including one death. Avoiding these types of errors requires more than one error reduction strategy. This article discusses strategies healthcare facilities can use to reduce the risk of oral medications being given intravenously. Separately, a new educational toolkit for managing drug shortages is available on the Authority's website.

Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls: Gait disturbances and immobility are risk factors that are highly correlated with a patient's risk for a fall. The Authority reviewed five years of event reports and found that of the class III obese patients who had mobility issues and fell, 7 percent of these falls were harmful enough to be classified as Serious Events (compared with 3 percent in the overall PA-PSRS population in 2011). Gait disturbances were identified in 68 percent of the reports of class III obese patients who fell. Strategies to reduce the risk of falls with class III obese patients with gait disturbances are discussed in the article, including:

  • a targeted risk falls assessment, implementation of falls prevention strategies and lift teams and lift equipment are essential items to assist in keeping class III obese patients safe when transferring, turning or ambulating.
  • Educational tools and consumer tips for the safety of class III obese patients are available on the Authority's website.

Strategies to Fully Implement Infection Control Practices in Pennsylvania Ambulatory Surgical Facilities: Some Pennsylvania ambulatory surgical facilities (ASFs) requested education on infection control practices and on the Centers for Medicare and Medicaid Services' (CMS) Infection Control Surveyor Worksheet after CMS revised the ambulatory surgical centers interpretive guidelines in 2009 with the addition of an infection control Condition for Coverage. Strategies for ASFs to fully implement infection control practices are discussed in this article that also provides a review of events submitted to the Authority from ASF facilities. A new educational tool is available on the Authority's website for ASF infection prevention.

Calculation of Outcome Rates That Diagnose Bedside Performance: Central-Line-Associated Bloodstream Infection: Authority analysts reviewed the National Healthcare Safety Network database to determine the dates of central-line associated bloodstream infection (CLABSI) infection events for calendar years 2010 through 2012 in Pennsylvania hospitals, along with accompanying dates of insertion for central venous catheters (CVCs).

The analysis shows that both the combined CLABSI rate and the CVC insertion infection rate trend lines are trending upward and that the CVC maintenance infection rate trend line is essentially flat. This article discusses how splitting CLABSI infection rates in a manner that correlates to the specific phase of CVC life enables clinicians to track insertion and maintenance performance. It also discusses the need for separate measurements to better target resources and improvement efforts. CLABSI educational tools and consumer tips are available on the Authority's website.

Wrong-Site Surgery Update: Sixteen wrong-site procedures were reported in Pennsylvania operating suites this quarter, resulting in a total of 46 for the year (July 2012 through June 2013), the lowest for any academic year since reporting began and the third lowest for any consecutive 12-month period, although this last quarter equaled the historical median. Nevertheless, the numbers are far below historical highs of 76 for an academic year and 82 for a consecutive 12-month period.

This article discusses how there is still work to be done in preventing wrong-site surgery. An updated toolkit and consumer tips are available on the Authority's website for wrong-site surgery prevention.

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