Common, Costly, and Concerning for Patient Outcomes
A new study published this week reports a dangerously high frequency of errors in electronic prescriptions. The review of 26,341 e-prescriptions found two-thirds contained inappropriate content of which almost 20% contained conflicting patient instructions in the free-text notes to the pharmacist. Not surprisingly, these free-texts cause confusion at the receiving pharmacy with significant workflow disruption, requiring one or more calls to the prescribing office to clarify the order. Beyond creating more work for the pharmacist and delaying the dispensing of the medication, the greater risk is that prescription errors can lead to an actual medication error of potential harm to the patient. The authors cite an example from the study in which a free text for the anticonvulsant Dilantin ordered twice the dose in the structured fields of the e-prescription. If not clarified by the pharmacy, these errors could result in harmful under or overdosage of the drug prescribed.
Almost 15% of the prescriptions reviewed for the study included a free-text message. Clearly this represents a failure of the intent of the "meaningful use" push to e-prescribing as an opportunity to improve efficiency and reduce errors. Why did caregivers feel the need to free-text? Most likely they were working in electronic medical records with a confusing, user-unfriendly interface.
Tip of the Iceberg?
E-prescribing errors may be only the tip of the iceberg of potential for errors in the EMR. A study of 258 EMR records after resident-performed cataract surgery found only about one-third were complete and accurate. Another recent report focusing on EMR-related errors in the emergency room suggested medication errors, misidentifying patients, and easily missing important patient information were common after EMR adoption. Most errors were attributed to poor EMR design rather than user errors. Errors in EMR often propagate as a result of the not uncommon caregiver practice of cutting and pasting information from prior notes into subsequent documentation. While strongly discouraged, this practice is sometimes a last resort for time-pressured, busy caregivers or their scribe surrogates using dated EMR technology.
The first step in reducing these errors is to fix the electronic medical record. Mistakes are more likely when a hurried clinician, hours behind schedule, trying to recall the specifics of a visit earlier in the day, is documenting in a clunky system. This solution begins with involvement of front-line caregivers in the build from the beginning. Understanding the real world workflow is a critical first step. A focus on improving the user experience by using available technology to build an interface that improves efficiency, reduces "click-burden" and decreases the need for free-texting is mandatory. Facilitating ease of documentation and ordering reduces the temptation to "cut and paste", actually improving the authenticity of the note.
I welcome your thoughts and comments as we work together to improve the care of our patients and take care of our caregivers.