A published paper in the Annuals of Emergency Medicine examines four clinical scenarios that that could result in use of an emergency department information system contributing to medical errors, with recommendations to make EDIS use more safe.

The scenarios cover communication failures, poor data displays, wrong order/wrong patient errors and alert fatigues. In one scenario, instance, a physician verbally asks a nurse to give a patient with a presumed kidney stone 1 mg of hydromorphone to ease discomfort, and a half-hour later the physician finds the patient difficult to arouse. The nurse tells the physician she gave three doses of 1 mg each. The physician asks the nurse how this happened. “Well, you remember you asked me to give 1 mg of hydromorphone while we spoke in the room, then you ordered another 1 mg in computerized physician order entry, with an as needed order for a third.”

The report, from a committee of the American College of Emergency Physicians, includes seven recommendations to help users and vendors improve EDIS safety: Appointment of an ED clinical champion to maintain an EDIS performance improvement process; creation of an EDIS performance improvement group; establishment of a review process to monitor ongoing safety issues with the EDIS; timely addressing by providers, administration and vendors of issues found under the review process; vendors and users should publicly share lessons learned from performance issues; vendors should learn from local patient safety improvements effort and timely distribute necessary changes; and vendor “hold harmless” or “learned intermediary” clauses should be removed from contracts.

The report is available here.

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