A report released by the Pennsylvania Patient Safety Authority has revealed that more than 300 medication errors took place at hospitals across the state over the past decade due to incorrect settings in hospital electronic medical health record (EHR) systems.
The errors were related to default settings used in EHR systems, which are commonly used to populate information for things such as commonly prescribed dosing protocols, and time for therapy delivery or lab draws. The intent of the default values is to improve efficiency and standardization, but the defaults can cause harm when not used properly. Analysts identified a total of 324 adverse events related to EHR software defaults.
The most common errors were related to medications, and included wrong time errors, wrong dose errors, and inappropriate use of an automated stopping function (meaning the medication was stopped prematurely). The three most common reasons for these failures were a failure to change the computer system’s default value, user-entered information being overridden by the computer system, and failure to completely enter information resulting in the computer inserting information in the blank parameters.
While there was a total of 324 events identified, 314 were reported as “event, no harm,” meaning that there was no adverse outcome for the patient. Six events were reported as “unsafe conditions” that did not lead to patient harm.
Two reports involved temporary harm to patients that required treatment or intervention: In one case a patient was given a higher than intended dose of muscle relaxant, in the second case a patient was given an extra dose of morphine. Two cases involved temporary harm to patients requiring a prolonged hospitalization. The first of these involved a patient developing a fever after an antibiotic was incorrectly discontinued; in the other case, a patient never received an ordered antidiuretic.
The researchers who conducted the study suggested three commonly reported error types that may deserve closer attention: wrong time errors, outdated value errors, and errors related to system-entered information. They suggested that wrong time errors may be avoided by paying attention to how the time information is entered into the system. The researchers also suggested that hospitals develop EHR system maintenance policies to make sure that the EHR defaults match current clinical practice.