Study Links Medical Errors to EHR Default Values

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A new study analyzes errors related to “default values” which are standardized medication order sets in electronic health records and computerized physician order entry systems.

The Pennsylvania Patient Safety Authority, an independent state agency, conducted the study. “Default values are often used to add standardization and efficiency to hospital information systems,” says Erin Sparnon, an analyst with the authority and study author. “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 health care facility within the EHR system for that type of surgery.”

These presets are the default value, but safety issues can arise if the defaults are not appropriately used. Sparnon studied 324 verified safety reports, noting that 314, or 97 percent, resulted in no harm. Six others were reported as unsafe conditions that caused no harm and four reports caused temporary harm involving some level of intervention.

The four cases requiring intervention involved accepting a default dose of a muscle relaxant that was higher than the intended dose, giving an extra dose of morphine because of an accepted default administration time that was too soon after the last dose, having a patient’s temperature spike after a default stop time automatically cancelled an antibiotic and rising sodium levels in a patient because confused wording made nurses believe that respiratory therapy was administering an ordered antidiuretic.

The most common types of errors in the study were wrong time (200), wrong dose (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 says. “There were also nine reports that showed a default needed to be updated to match current clinical practice.”

The report, “Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values,” is available here.

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