TY - JOUR
T1 - Orders on file but no labs drawn
T2 - Investigation of machine and human errors caused by an interface idiosyncrasy
AU - Schreiber, Richard
AU - Sittig, Dean F.
AU - Ash, Joan
AU - Wright, Adam
N1 - Funding Information:
This work was supported by the National Library of Medicine of the National Institutes of Health, grant number R01LM011966. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Publisher Copyright:
© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved.
PY - 2017/9/1
Y1 - 2017/9/1
N2 - 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.
AB - 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.
KW - CPOE
KW - Clinical decision support
KW - Medical order entry systems
KW - User computer interfaces
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U2 - 10.1093/jamia/ocw188
DO - 10.1093/jamia/ocw188
M3 - Article
C2 - 28339629
AN - SCOPUS:85031928519
SN - 1067-5027
VL - 24
SP - 958
EP - 963
JO - Journal of the American Medical Informatics Association
JF - Journal of the American Medical Informatics Association
IS - 5
M1 - ocw188
ER -