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Original Investigation
May 14, 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

Author Affiliations
  • 1Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
  • 2Departmentof Quality and Patient Safety, NewYork-Presbyterian Hospital, New York
  • 3Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York
  • 4Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York
  • 5Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York
  • 6Montefiore Health System, Bronx, New York
  • 7Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York
  • 8Division of Internal Medicine, Department of Medicine, Harvard Medical School, and Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts
  • 9Primary Care Center, Harvard Medical School, Department of Medicine, Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 10Division of General Internal Medicine, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
  • 11Department of Emergency Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
  • 12Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, and Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, Massachusetts
  • 13Departments of Sociology and Biomedical Informatics, University of Pennsylvania, Philadelphia
  • 14Department of Biomedical Informatics, University at Buffalo (SUNY), Buffalo, New York
  • 15Department of Medicine, Division of Academic Medicine and Geriatrics, and Departments of Pharmacy Practice and Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago
  • 16Department of Communication Studies, Center for Communication and Health, Northwestern University, Evanston, Illinois
  • 17Institute for Safe Medication Practices, Horsham, Pennsylvania
  • 18Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York
JAMA. 2019;321(18):1780-1787. doi:10.1001/jama.2019.3698
Visual Abstract.
Visual Abstract.
Effect of Restriction of Concurrently Open Records in an EHR on Wrong-Patient Order Errors
Effect of Restriction of Concurrently Open Records in an EHR on Wrong-Patient Order Errors
Key Points

Question  Does limiting clinicians to 1 electronic patient record open (restricted) reduce wrong-patient orders vs allowing up to 4 records open concurrently (unrestricted)?

Findings  In this randomized trial that included 3356 clinicians and 4 486 631 order sessions, the error rate in the restricted vs unrestricted group was 90.7 vs 88.0 per 100 000 order sessions, a difference that was not statistically significant. However, clinicians in the unrestricted group completed 66.2% of order sessions with only 1 record open.

Meaning  Although restricting the number of concurrently open electronic patient records did not reduce wrong-patient orders, the proportion of orders placed with a single record open in the unrestricted group limited the study’s power to detect an effect of opening 4 records concurrently.

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

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