One of the most common causes of medical error encountered in current electronic medical record (EMR) use is that a providers are placing incorrect orders in the patient’s EMR, a recent study noted (Pediatrics 2012 June 4 [Epub ahead of print]).
According to the study, e-records have not entirely eliminated human error. The study examined whether including a patient photograph on a verification screen in the EMR would reduce such errors.
A quality improvement program at Children’s Hospital Colorado in 2009 found that misplaced orders were, in fact, the second most common reason that patients received inappropriate care—making up 24% of reported errors. To cut down on such errors, the hospital changed its computer system so that all orders for tests or treatments triggered an “order verification screen” which included a photograph of the pediatric patient.
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The new system proved highly effective. In 2010, the hospital had a dozen incidents where a child received care intended for another patient due to misplaced orders. In 2011, that number had dropped to three, and in all three cases there was no photo in the child’s EMR record.
Furthermore the program showed that in EMRs that contained a photo of the patient, there was not a single instance of misplaced or mistaken orders.
Dr. Daniel Hyman, the chief quality officer at the Colorado, hospital and lead researcher explained that physicians may have multiple records open onscreen at one time and think they are writing in one patient’s chart when they are really entering an order into another.
He said that his hospital added the photos by using a digital camera, and that other hospitals could easily do the same using inexpensive technology.
However, Dr. Hyman noted that one problem that sometimes comes up is that some parents don’t want their child’s picture incorporated for privacy issues. Making parents aware that the use of a photo is to aid their children’s safety might avoid that problem.
