Classics and Emerging Classics

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case and the institution’s root cause analysis, the authors identify 17 distinct errors that culminated in the procedure taking place. The authors discuss the role of the individual versus the system, the existing culture contributing to the error, and strategies to avoid similar errors in the future. This article is part of a special collection entitled “Quality Grand Rounds,” a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.