A major medical center has been experiencing a spate of "wrong orders" with its EHR. After studying the problem, officials have determined that the best solution involves decreasing the number of open charts allowable from the current four to a maximum of two. With its prior legacy EHR and with the capability of opening only one e-chart, the wrong order problem had not been previously broadly encountered. Hospital officials surveyed other academic health systems across the country and found that this problem was not unique to it. Most of the other hospitals had also found it necessary to decrease the maximum number of allowable open charts from the default setting of four.
I performed a Google search for "wrong orders" associated with EHRs and discovered that the acronym COWPIE (Charting On Wrong Patient In EHR) is now being used to describe this problem (see: Wrong-Patient Orders). Here's a quote from this article about the extent of the COWPIE problem in a pediatric hospital:
In the children’s hospital studied, automated surveillance identified 644 probable CPOE COWPIEs. Only four had been reported to risk management, presumably events in which the wrong patient received the medication. The great majority of these events appeared to qualify as near misses, with the errant order rapidly cancelled and replaced with the correct order for the correct patient.
It's of some interest in this cites study how the COWPIEs were identified ex post facto. Here's a description of the method:
if a provider 1) ordered a drug on a patient, 2) cancelled the order within 120 minutes, and 3) then reordered the same drug on a different patient within 5 minutes of cancellation, it is presumed to be an error. When the authors performed chart reviews on a subset of these automatically identified “errors”, they found that at least 60 percent and perhaps as many as 100 percent of the charts confirmed the error (documentation of the reasons for the provider’s actions often was ambiguous).
It's clear, even from these brief reports, that "wrong order" errors with EHRs are both very common and underreported. I raised this issue in a blog note about two years ago: Physician & Nurse Involvement in EHR Design; Patient Safety and EHR Gag Clauses. In that note, I linked to an article on EHR design (see: Clinician Involvement Critical in EHR Design, Improvement) and here is a quote from that article:
Some vendors prohibit users from sharing hazards even in the academic literature. Although EHR systems that are marketed and sold to hospitals and healthcare providers are certified by the Certification Commission for Health Information Technology, that process is not focused on safety issues....and no mechanism exists to allow or encourage system users to address ongoing safety issues or provide feedback.
As far as I can tell and as illustrated by the case described above at a major medical center, EHR wrong order remediation issues are being resolved at the local level with other hospital experiences confirmed by telephone surveys. This kind of remediation based on local detection and effort does not lend itself to national organized efforts to reduce errors and improve patient safety on a broader basis.