52 Limiting the Number of Open Charts in the Electronic Medical Record Does Not Decrease Order Errors in the Emergency Department

In the ED, clinicians maintain multiple patient charts open simultaneously to facilitate rapid access as they multi-task. Little is known about the rate of errors from orders being entered on the wrong patient as a consequence of this practice in this setting. Our health system limited the number of active simultaneously open charts from 4 to 2 to potentially reduce errors. Retract-and-reorder, which is defined as an order written for one patient that was retracted (or canceled) then ordered on a different patient within 10 minutes, reflects that an order was entered on an incorrect patient and serves as a marker for order error (Adelman J et al. J Am Med Inform Assoc. 2013). We sought to examine the impact of limiting the number of open active EMR charts on retract and reorder errors in the EDs of a large integrated health system. A retrospective chart review was performed on all patient encounters presenting to one of 11 EDs in a large integrated health system with the same EMR for 6 months prior to and after the intervention was enacted (n=1,161,777). Inclusion criteria included any patient with an active ED visit during the study period. Secondary analysis of error rate by hospital type (teaching and non-teaching) was performed. We compared the error rate per one thousand patient-hours using two-tailed student’s T test, with a cutoff of p<0.05 for statistical significance. The error rate per one thousand patient-hours decreased from 0.85 pre-intervention to 0.82 post-intervention, representing a 3.65% reduction (Figure). This was not statistically significant (p=0.60). The error rate by hospital type was also not significantly different (0.98 pre-intervention to 1.02 post-intervention, p= 0.70, teaching hospitals; 0.78 pre-intervention to 0.71 post-intervention, p=0.38, non-teaching hospitals). Additionally, no difference in error was noted by hour of day or patient workload. Limiting the number of simultaneously open patient charts did not significantly reduce the rate of retract-and-reorder for ED patients. No effect was observed in both teaching and non-setting settings. Further investigation into the factors that contribute to wrong patient ordering in the EMR is warranted.