Report Explores EDIS Patient Safety Concerns

The loud moaning draws you into room 10, where you find a patient rocking back and forth, holding his right flank. “He says it is his kidney stones,” informs the nurse.  After a cursory examination, you ask the nurse to give him 1 mg of hydromorphone to ease his obvious discomfort. You then receive an urgent request to reevaluate a critical patient. Finally, you sit down at a computer station to chart and enter orders for the patient with the presumed kidney stone. Half an hour later, you check in on the patient and he is difficult to arouse. “How many mg of hydromorphone did the patient get?” you inquire.   The nurse tells you 3 doses of 1 mg each. “How did that happen?” “Well you remember you asked me to give 1 mg of hydromorphone while we were in the room, then you ordered another 1 mg in computerized physician order entry with an as needed order for a third.”

Although electronic health records systems are designed to improve care through better access to information, this fictional scenario is one of four presented in a paper recently published in the Annals of Emergency Medicine that illustrates how the use of an emergency department information system (EDIS) could actually hinder patient safety. This particular scenario highlights communication failures, while the others illustrate poor data displays, wrong order/wrong patient errors and alert fatigues.

The report offers seven recommendations to improve the safety of ED information systems:

  • The appointment of an ED clinician to maintain a performance improvement process for the EDIS
  • The formation of a multidisciplinary EDIS performance improvement group that meets regularly with hospital and ED leadership
  • The establishment of a review process to examine EDIS performance improvement issues
  • Timely addressing of the performance improvement issues by ED providers, vendors and administrators
  • The sharing of performance improvement lessons learned with other EDs using the same EDIS
  • Timely distribution of necessary changes to all installation sites from the EDIS vendor
  • The removal of “hold harmless” or “learned intermediary” clauses from vendor contracts