Limiting EMR Chart Access May Not Reduce Error Rates

Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

Perhaps no other specialty in medicine deals with constant task switching as much as emergency medicine. It happens frequently during a shift when you are in the middle of one task and get interrupted to place an order for a different patient. There is a certain cognitive load to keeping your current task in mind while switching charts in your electronic medical record (EMR) system. You see a message that you are not able to open another chart, you must close an open chart first; this inevitably causes frustration. A major reason for the limitation in the number of open charts is to minimize orders being accidentally placed for the wrong patient, an argument that superficially makes sense. However, limiting the number of open charts does not limit the number of patients being cared for at the same time.

A new study sought to establish whether a lower limit of open charts in the EMR led to a reduction in accidental orders being placed for the wrong patient.¹ The researchers performed a retrospective chart review at 13 emergency departments where they counted retract-and-reorder events, which were defined as a procedure or medication order that was placed, retracted, and reentered on a different patient within 10 minutes. While limited, this simple approach can be expected to catch a number of mistaken entry errors. The researchers studied two periods of evaluation with limits of either two or four open charts.

Their findings showed retraction rates of 2.4 per thousand when four charts could be opened versus 2.2 per thousand when only up to two charts could be simultaneously opened. Ultimately, there was no statistically significant difference in the rates of retract-and-reorder events, the chosen proxy for these near-miss medical errors.

While this study is not sufficiently rigorous to conclude with certainty that limiting concurrently open charts does not reduce error rates, it provides some evidence that runs opposite to recommendations offered by The Joint Commission to limit open charts to only one. In my opinion, the loss of efficiency with fewer open charts without a verifiable increase in patient safety does neither the doctor nor the patient any good.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions and the Emergency Medicine Residents’ Association.

Dr. Schmitzberger is an emergency medicine resident at the University of Michigan.