R E V I E W S & A N A LY S E S Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values Erin Sparnon, MEng INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Default values are often used to add standardization and efficiency to hospital infor- mation systems like electronic health record (EHR) and computerized provider order entry (CPOE) systems, and they can take many forms. Default values for medication, ABSTRACT dose, and route are often found in standardized medication order sets to reduce the Hospitals use default values in elec- likelihood of a medication ordering error for commonly prescribed therapies from tronic health record (EHR) systems in which most patients can benefit from a standard therapeutic regimen (e.g., pain con- a variety of ways (e.g., prepopulating trol for a healthy patient after surgery). Default values for time are often inserted into commonly prescribed dosing protocols, medication and lab-draw orders to coordinate staff resources (unless the provider speci- coordinating times for therapy delivery fies another time such as “now” or “stat”). Automated stopping (auto-stop) values are or lab draws). Using a keyword query, used to discontinue medications or therapies after a certain amount of time unless a analysts identified 324 events related provider renews the order. to EHR software defaults reported to the Although the use of default values is intended to improve efficiency and standardiza- Pennsylvania Patient Safety Authority. tion, reports submitted to the Pennsylvania Patient Safety Authority indicate that The three most commonly reported patient harm can occur when a default value is used inappropriately. In an earlier error types were wrong-time errors analysis, the Authority investigated events related to the use of EHRs reported through (n = 200), wrong-dose errors (n = 71), the state’s mandatory reporting system,1 and errors related the use of default values and inappropriate use of an automated- were identified as warranting further study. stopping function (n = 28). Many of these reports also indicated a source of METHODS the erroneous data (n = 168), and the three most commonly reported sources Reports in the Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) were failure to change a default value database include narrative descriptions of the event as well as user-assigned tags for (n = 128), user-entered values overwrit- event type (e.g., fall, surgical error) and harm score (ranging in severity from near-miss ten by the system (n = 19), and failure situations through death). Authority analysts queried the PA-PSRS database using to completely enter information, caus- the keyword strings “not activ,” “inactiv,” “default,” “chang,” “setting,” “control,” and ing the system to insert information into “automat.” Search terms were truncated to allow for a “wild card” effect: the query blank parameters (n = 16). Analysts term “inactiv” would return reports containing the terms “inactive,” “inactivated,” also noted nine reports indicating that a “inactivation,” and so on. default value needed to be updated to The query returned 1,249 reports of events that occurred from June 19, 2004, through match current clinical practice. Facilities February 15, 2013. This data set contained a large number of reports unrelated to the may wish to pay particular attention to use of default values, and analysts noted that the term “default” had the best specific- the types and sources of error identi- ity. Analysts selected the 487 reports that included the term “default” and manually fied in this analysis when considering verified that 324 of these were relevant to this issue. Analysts excluded 163 reports their use of default values in order sets, that were not related to default settings in EHR technology; most of these related to including consideration of how users inappropriate use of default settings on medical devices such as infusion pumps, defi- view and enter time information, peri- brillators, and suction regulators. odic review and change management, and differentiation between information RESULTS that is user-entered versus overwritten or Classification by Harm Score populated by the system. (Pa Patient Saf Of the 324 verified reports, 314 (97%) were reported as “event, no harm” (i.e., an error Advis 2013 Sep;10[3]:92-5.) did occur, but there was not an adverse outcome for the patient), and 6 (2%) were reported as “unsafe conditions” that did not result in a harmful event. Two reports involved temporary harm to the patient that required treatment or intervention (user- reported harm score E); these events were associated with, respectively, acceptance of a default dose of muscle relaxant (which was higher than the intended dose) and an extra dose of morphine due to acceptance of a default administration time (which was too soon after the patient’s last dose). Two reports involved temporary harm that required initial or prolonged hospitalization (user-reported harm score F). Page 92 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority In the following report, the patient did Classification by Reported — Dose: The default dose value did not receive the ordered antibiotic after a Event Type not match the clinician order default stop time automatically cancelled Of the 324 identified reports, the most (22%, n = 71). the order. frequently reported event type was medi- — Auto-stop: The medication was [During the evening, a] patient was cation error (95%, n = 307). These reports stopped prematurely when the sys- ordered [an antibiotic]. The order was were distributed among subclassifications, tem’s automatic stops were engaged entered [30 minutes later] with a including wrong time (17%, n = 52), inappropriately (8%, n = 26). 48-hour stop time [default]. The first extra dose (16%, n = 51), dose omission — Route: The default route (e.g., intra- dose was sent up at that time. The (16%, n = 51), and wrong dose/overdos- muscular, oral, intravenous) did first dose was returned to pharmacy age (10%, n = 34). (See the Table.) not match the intended route later that evening, and the next two (6%, n = 21). doses were given as scheduled. . . . Default-Related Failure Modes Two reports were tagged with two event The order was not renewed, [it] fell Because events related to the use of default types each (wrong time and route, wrong off the profile, and no other antibiot- values spanned several of the Authority’s dose and auto-stop), and eight reports ics were ordered for the next two event types, analysts reviewed the 324 indicated other, scattered problems with days. On [day three], the patient’s relevant event reports for common threads default values unrelated to medication temperature spiked at 102.3. The and categorized the events as follows: process, such as a default printer setting physician was called and ordered the sending a label to the wrong location, — Time: The default time value did [antibiotic] to be continued. default “normal” lab result entry, default not match the clinician order or the In the following report, the patient did patient’s needs (62%, n = 200). protocols (e.g., insulin, respiratory not receive the ordered antidiuretic due therapy) that were inappropriate for the to a miscommunication as to which care- giver would administer the medication. Table. Classification by Reported Event Type The default value in the CPOE system EVENT TYPE NO. OF REPORTS indicated that respiratory therapy was to Medication error 307 administer the medication, but this did Dose omission 51 not match the hospital’s clinical practice. Extra dose 52 DDAVP [antidiuretic] nasal spray Wrong 147 was ordered bid [given twice that Dose/overdosage 34 same day]. Multiple missed doses Dose/underdosage 10 were noted on the MAR [medication administration record]. Physician Drug 2 questioned the [registered nurse] car- Dosage form 2 ing for the patient about whether Duration 7 the patient was receiving DDAVP Rate (intravenous) 2 as ordered, since sodium levels were Route 18 increasing despite DDAVP bid and Strength/concentration 5 strict free-water restriction. Upon Technique 4 investigation, [it was] noted that five Time 62 doses were not given. Upon further Patient 1 investigation, [it was discovered that Prescription/refill delayed 6 the system] default order has the box checked for “per [respiratory therapy] Medication list incorrect 9 protocol.” . . . Respiratory therapy Monitoring error (includes contraindicated drugs) 1 does not administer this medication, Unauthorized drug 2 despite the fact that this is the default Other (specify) 39 order selection and the fact that it is Error related to procedure, treatment, or test 16 listed “per [respiratory therapy] proto- Other/miscellaneous 1 col” on the MAR. Total 324 Vol. 10, No. 3—September 2013 Pennsylvania Patient Safety Advisory Page 93 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S patient, or records filed under a default — Inability to change a default value Of the remaining 460 regimen order physician. (2%, n = 5). Reports explicitly men- sets, all had at least some changes recom- Analysts also investigated the reported tioned that a user was trying to enter mended: 75% had title changes, 14% had origin of error, which was relevant and a value other than the default but cycle-related changes, 31% had reference available in 168 reports. was unable to do so. updates, and 13% had dosing updates.7 Order placed for digoxin 0.25 mg Problems originating in the use of EHRs Q6h [every six hours], first dose stat, CONCLUSION — Failure to change a default value at [midafternoon]. The order set for Overall, 324 events were identified that (40%, n = 128). Reports explicitly digoxin load did not allow orderer to described problems related to default mentioned that a user forgot to place a stat order, and the first dose values in EHR software. Reports of change a default value. defaulted to [over five hours later]. wrong-time errors were the most preva- Pharmacist did not change the Since the stat dose was omitted, that lent, followed by wrong-dose errors, default [dose] of the medication when order was discontinued. inappropriate use of auto-stops, and entering into computer system. In addition to considering the stated cause wrong-route errors. When available, the — Failure to enter a complete order, and result of the event, analysts also identi- cause of the error was assessed as well; resulting in the inappropriate use fied nine reports that explicitly stated that failure to change a default value was of a default (5%, n = 16). Reports the default needed updating because it did reported most frequently, followed by user explicitly mentioned that a user not match current clinical practice, indicat- entries overwritten by the system, default entered an order that was missing ing that the problem originated with the values inserted into incomplete orders, certain order parameters and these implementation of the EHR system. and inability to change a default value. order parameters were later filled in Analysts also noted that several reports with default values. DISCUSSION indicated that a default value needed to Physician entered order into [the be updated to match clinical practice. Health information technology systems CPOE] but did not include the such as CPOE can be important tools in The event narratives analyzed in this number of tablets. Without all of the reducing drug-related injury and harm, report suggest three commonly reported information, the number of tablets especially if installed systems are refined error types that may warrant closer ordered through [the CPOE] went to and tailored to match clinical practice.2 attention: a default number in excess of what Tailoring CPOE systems to clinical practice 1. Wrong-time errors. To address the pharmacy would send. Physician can also benefit clinicians, as disease- wrong-time errors, facilities can pay had to rewrite the prescription and specific and care-specific order sets can particular attention to the manner resend it to the pharmacy. The result help improve acceptance and adoption by which time information is entered was that the patient did not receive over more generic order sets.3,4 However, by users and the manner in which four doses. literature suggests that (1) the default values time information is relayed to users Problems originating in the design of EHRs used in order sets and clinical decision after selection. This can include support must match a particular care area’s assessing how and whether a user — User entry overwritten by the system clinical practice in order to be helpful and can specify times for particular types in favor of a default value (6%, (2) facilities should be wary of wholesale of orders (e.g., medications, lab n = 19). Reports explicitly mentioned acceptance of default values supplied by the draws); implementing user training that a user had entered a value that EHR supplier.5 To make best use of safety to ensure that users know the dif- was then overwritten by the system resources, facilities may wish to concentrate ference between selecting “stat” or and replaced with a default value. on developing and refining a more limited “now,” selecting a specific time, and Doctor ordered [early] calcium level. set of order sets that cover the highest-usage accepting the next standard time for Lab was entered to be picked up at and highest-risk clinical pathways.6 the administration or procedure; and [early time] but defaulted to [morn- After development and validation, ensuring that, after selection, the ing] lab draw. Doctor entered the facilities can plan for the ongoing main- system clearly displays the selected patient’s room at [later time] to assess tenance of order sets. A study of 511 time (e.g., “This dose will be given in the patient and found the lab tech chemotherapy order sets conducted by the next general medication round at was just drawing the blood. US Oncology found that 51 were recom- 0800 tomorrow.”). mended for removal or consolidation. Page 94 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority 2. Errors related to outdated values. To sets and clinical decisions support (whether default values are written address errors related to situations in current clinical practice,8 as well as over user-entered information or which default values have not kept change management procedures for inserted into incomplete entries), up with changes in clinical practice, updating these systems once gaps are facilities can determine whether facilities can develop EHR system identified.9,10 EHR software allows users to easily maintenance policies that require 3. Errors related to system-entered differentiate between user-entered periodic assessment of whether order information. To address these errors data and system-entered data. NOTES 1. Sparnon E, Marella WM. The role of set. J Am Med Inform Assoc 2011 May 8. Butcher L. How health IT is changing the the electronic health record in patient 1;18(3):322-6. practice of oncology: case study—clinical safety events. Pa Patient Saf Advis [online] 4. Maslove DM, Rizk N, Lowe HJ. Comput- decision support. Oncol Times 2012 Nov 2012 Dec [cited 2013 May 1]. http:// erized physician order entry in the critical 10;34(21):35-6. patientsafetyauthority.org/ADVISORIES/ care environment: a review of current 9. Leu MG, Morelli SA, Chung OY, et al. AdvisoryLibrary/2012/Dec;9(4)/ literature. J Intensive Care Med 2011 May- Systematic update of computerized physi- Pages/113.aspx Jun;26(3):165-71. cian order entry order sets to improve 2. Leung AA, Keohane C, Amato M, et al. 5. Mullen K. Easing the paper-to-EHR quality of care: a case study. Pediatrics 2013 Impact of vendor computerized physician transition. Health Manag Technol 2012 Mar;131 Suppl 1:S60-7. order entry in community hospitals. J Gen Apr:33(4):18-20. 10. McGreevey JD 3rd. Order sets in elec- Intern Med 2012 Jul;27(7):801-7. tronic health records: principles of good 6. McGreevey JD 3rd. Order sets in elec- 3. Munasinghe RL, Arsene C, Abraham tronic health records: principles of good practice. Chest 2013 Jan;143(1):228-35. TK, et al. Improving the utilization of practice. Chest 2013 Jan;143(1):228-35. admission order sets in a computerized 7. Busby LT, Sheth S, Garey J, et al. Creating physician order entry system by integrat- a process to standardize regimen order ing modular disease specific order subsets sets within an electronic health record. J into a general medicine admission order Oncol Pract 2011 Jul;7(4):e8-14. Vol. 10, No. 3—September 2013 Pennsylvania Patient Safety Advisory Page 95 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 3—September 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. 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