Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.
Approach to Improving Safety
Setting of Care
Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.