Penn. Patient Safety Authority explores “default value” EHR errors

A recent study sheds light on the most common types and sources of EHR errors that are related to default values, or medication, dose and delivery values already preset by the healthcare facility within the EHR system.

Researchers identified 324 events related to default values in EHR software. Reports of wrong-time errors were the most prevalent, followed by wrong-dose errors, inappropriate use of auto-stops and wrong-route errors, according to the study, which appeared in the September issue of Pennsylvania Patient Safety Advisory.

Failure to change a default value was most frequently reported as the cause of an error. User entries overwritten by the system, default values inserted into incomplete orders and inability to change a default value also were discovered as sources of errors.  

Of the 324 verified reports, 314 were reported as "event, no harm" meaning an error did occur, but there was no harm to the patient, according to the report; six were reported as “unsafe conditions,” which did not result in a harmful event. Of the total reports, two caused harm that required treatment or an intervention: one related to the administering of a dose of morphine too soon after the last dose and the other involved use a default dose of muscle relaxant that was higher than the intended dose.

"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," wrote author Erin Sparnon, MEng, patient safety analyst for the Pennsylvania Patient Safety Authority.

The view the entire study, "Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values," go here.