Report offers methods to improve ED IS

A new report offers four clinical scenarios that could result in use of an emergency department information system (EDIS) contributing to medical errors as well as recommendations to make the systems safer to use.

The paper was published in the Annuals of Emergency Medicine.

The scenarios cover communication failures, poor data displays, wrong order/wrong patient errors and alert fatigue. In one scenario, for example, 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.”

A committee of the American College of Emergency Physicians developed the report, which includes seven recommendations to help users and vendors improve EDIS safety:

1. Appointment of an ED clinical champion to maintain an EDIS performance improvement process;
2. Creation of an EDIS performance improvement group;
3. Establishment of a review process to monitor ongoing safety issues with the EDIS;
4. Timely addressing by providers, administration and vendors of issues found under the review process;
5. Vendors and users should publicly share lessons learned from performance issues;
6. Vendors should learn from local patient safety improvements efforts and timely distribute necessary changes; and
7. Vendor “hold harmless” or “learned intermediary” clauses should be removed from contracts.

The report is available here.