Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.
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.
Holy Spirit-A Geisinger Affiliate, Camp Hill, PA, USA.
Richard
R
Schreiber
University of Texas Health Science Center at Houston's School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX, USA.
Dean F
DF
Sittig
Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, OR, USA.
Joan
J
Ash
Brigham & Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Partners HealthCare, Boston, MA, USA.
Adam
A
Wright
D002984:Clinical Laboratory Information Systems / Q000458:organization & administration*; D019411:Clinical Laboratory Techniques; D000073892:Health Information Interoperability; D006801:Humans; D019300:Medical Errors; D050316:Medical Order Entry Systems / Q000458:organization & administration*; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D019982:Organizational Case Studies; D014584:User-Computer Interface
CPOE; clinical decision support; medical order entry systems; user computer interfaces