Orders on file but no labs drawn: Investigation of machine and human errors caused by an interface idiosyncrasy

Richard Schreiber, Dean F. Sittig, Joan Ash, Adam Wright

Research output: Contribution to journalArticle

6 Scopus citations

Abstract

In this report, we describe 2 instances in which expert use of an electronic health record (EHR) system interfaced to an external clinical laboratory information system led to unintended consequences wherein 2 patients failed to have laboratory tests drawn in a timely manner. In both events, user actions combined with the lack of an acknowledgment message describing the order cancellation from the external clinical system were the root causes. In 1 case, rapid, near-simultaneous order entry was the culprit; in the second, astute order management by a clinician, unaware of the lack of proper 2-way interface messaging from the external clinical system, led to the confusion. Although testing had shown that the laboratory system would cancel duplicate laboratory orders, it was thought that duplicate alerting in the new order entry system would prevent such events.

Original languageEnglish (US)
Article numberocw188
Pages (from-to)958-963
Number of pages6
JournalJournal of the American Medical Informatics Association
Volume24
Issue number5
DOIs
StatePublished - 2017

Keywords

  • CPOE
  • Clinical decision support
  • Medical order entry systems
  • User computer interfaces

ASJC Scopus subject areas

  • Health Informatics

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