EHR adverse events data cause for alarm

Software default values, though implemented for safety, are proving in many cases to be harmful for patients if not used properly
By Erin McCann
11:12 AM
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After analyzing more than 300 event reports related to EHR software default values, more than 3 percent were found to result in unsafe conditions or prolonged hospitalization for patients, according to a new report by the Pennsylvania Patient Safety Authority. 
 
The report analyzed 324 EHR default values – which are the preset medication, dose and delivery – that led to events, with the aim of giving state healthcare facilities valuable data to avoid EHR events such as wrong-time and wrong-dose errors in the future. 
 
"Default values are often used to add standardization and efficiency to hospital information systems," said Erin Sparnon, patient safety analyst for the Pennsylvania Patient Safety Authority, in a news release. "For example, a healthy patient using a pain medication after surgery would receive a certain medication, dose and delivery of the medication already preset by the healthcare facility within the EHR system for that type of surgery."
 
However, EHR event reports show that patient harm can sometimes occur if these defaults are not used appropriately.
 
Sparnon said two of the reports involved temporary harm that required initial or prolonged hospitalization. 
 
 
In the first report, a patient's temperature spiked after a default stop time automatically cancelled an antibiotic. In the second report, a patient's sodium levels continued to rise because a default note to administer an ordered antidiuretic "per respiratory therapy" caused nurses not to administer the drug because they incorrectly assumed respiratory therapy was doing so.
 
Two reports involving temporary harm that required treatment or intervention involved accepting a default dose of muscle relaxant which was higher than the intended dose, and giving an extra dose of morphine by accepting a default administration time which was too soon after the patient's last dose, according to the data. 
 
Six were reported as "unsafe conditions" that didn't result in an obvious harmful event, and 314, or 97 percent, were reported as having an error, but with no obvious harm to the patient. 
 
The three most commonly reported error types were wrong-time errors (200), wrong-dose errors (71) and inappropriate use of an automated-stopping function (28).
 
"Many of these reports also showed a source of erroneous data, and the three most commonly reported sources were failure to change a default value, user-entered values being overwritten by the system and failure to completely enter information which caused the system to insert information into blank parameters," Sparnon said. "There were also nine reports that showed a default value needed to be updated to match current clinical practice."
 
 
"The analysis shows that healthcare providers should consider their use of default values in order sets particularly when considering how users see and enter time information, how they address errors related to situations in which default values have not kept up with changes in clinical practice and consider whether EHR software allows users to easily tell the difference between user-entered data and system-entered data," added Sparnon.
 

Other serious errors identified by the authority include oral medications given intravenously (20 reports) and wrong site of surgery on patient (46 total reports for the year).