Emergency physicians have a difficult job. In no other profession can a person be interrupted more than once every 10 minutes while being asked to make critical lifesaving and life-altering decisions.¹ Even when interruptions are minimal, working long and odd hours can induce erroneous judgment if we are not careful with our decision making.

I remember the combination of fatigue and inexperience during my internship year when I was writing orders on a newly admitted patient before leaving the hospital after a 24-hour shift. Walking around the ICU on rounds, I suddenly remembered that I had written for the wrong medication. Before an error could happen, I was able to go back and change the order. Back then, orders were written on paper, they weren’t executed rapidly or in real time, and you could only write in one chart at a time because you had to have the thick binder of the patient’s medical record physically open in front of you. Following the advent of electronic medical records, it has become even easier to mix charts and extraordinarily simple to place the wrong order on the wrong person.

Whenever I try to order a dose of ketorolac on a patient who neglected to tell me that they are allergic to ibuprofen, the computer alerts me to this potential adverse event. But the computer can’t tell me if I am ordering a medicine for the wrong patient or a test for the wrong person or an X-ray on the incorrect side of the body. To reduce errors such as these, The Joint Commission and the Office of the National Coordinator for Health Information Technology have suggested that physicians should only open one chart at a time on their computer screens. Based on expert opinion alone, this restriction promises improved patient safety. It also threatens efficiency, which, in the emergency department, is one of a physician’s greatest commodities. This month’s journal club article at right explores this assumption. It shows that when a medical system reduced the number of open charts that physicians were allowed to access simultaneously from four to two, mistaken entry errors—orders that were “placed, retracted, and reentered on a different patient”—decreased.²

Once quantified, the rate at which errors declined meant that for every 5,000 orders, only one would be changed. Extrapolating this to my high-volume urban emergency department, could that mean that only 20 patients out of every 100,000 would have an order entry error? Is that level of restriction worth it? A report by Kaiser Health News entitled “Death by 1,000 Clicks” detailed the new types of errors that have become prominent as we have expanded our medical records into the digital age.³ While we have certainly reduced problems with illegible handwriting and standardized protocols, we’ve also made it more difficult to do seemingly simple tasks. Reducing the emergency physician’s ability to multitask does not benefit our patients—it just promises to be another impediment to the practice of medicine. A second study, a randomized trial testing The Joint Commission’s “expert opinion” to limit physicians to one open chart at a time, similarly showed that emergency physicians do not need to sacrifice efficiency for safety.⁴  

References

1. Westbrook JI, Coiera E, Dunsmuir WTM, et al. The impact of interruptions on clinical task completion. Qual Saf Health Care. 2010;19(4):284-289.
2. Canfield C, Udeh C, Blonsky H, et al. Limiting the number of open charts does not impact wrong patient order entry in the emergency department. J Am Coll Emerg Physicians Open. 2020;1(5):1071-1077. 
3. Schulte F, Fry E. Death by 1,000 clicks: where electronic health records went wrong. Kaiser Health News website. Accessed Aug. 20, 2021.
4. Adelman JS, Applebaum JR, Schechter CB, et al. Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial. JAMA. 2019;321(18):1780-1787.