title: The hazard of software updates to clinical workstations: a natural experiment.
abstract: Emergency department (ED) electronic tracking boards provide a snapshot view of patient status and a quick link to other clinical applications, such as a web-based image viewer client to view current and previous radiology images from the picture archiving and communication systems (PACS). We describe a case where an update to Microsoft Internet Explorer severed the link between the ED tracking board and web-based image viewer. The loss of this link resulted in decreased web-based image viewer access rates for ED patients during the 10 days of the incident (2.8 views/study) compared with image review rates for a similar 10-day period preceding this event (3.8 views/study, p<0.001). Single-click user interfaces that transfer user and patient contexts are efficient mechanisms to link disparate clinical systems. Maintaining hazard analyses and rigorously testing all software updates to clinical workstations, including seemingly minor web-browser updates, are important to minimize the risk of unintended consequences.
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. alandman@partners.org
authors.forename: Adam B
authors.initials: AB
authors.lastname: Landman
authors.forename: Sukhjit S
authors.initials: SS
authors.lastname: Takhar
authors.forename: Samuel L
authors.initials: SL
authors.lastname: Wang
authors.forename: Anabela
authors.initials: A
authors.lastname: Cardoso
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Kosowsky
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
authors.forename: Eric G
authors.initials: EG
authors.lastname: Poon
mesh_terms: D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D019982:Organizational Case Studies; D057386:Search Engine; D012984:Software; D014584:User-Computer Interface
keywords: PACS; emergency care information systems; information systems; radiology information systems; user-computer interface