A new study found that limiting the number of open charts doesn’t reduce wrong orders.
How many electronic charts will your hospital let you open, simultaneously?
What you may think is a technical constraint is, in fact, a local policy decision – and until recently, one without any good evidence behind it. Surveys suggest hospitals are all over the place on this issue, with some allowing just one open chart while others allowing four, and many falling in between.
A lot of administrators simply assumed that allowing more open charts translates to more chance for errors, like placing orders on the wrong patient. But of course you can still place wrong orders when only one chart is open, and working with multiple charts simultaneously may lead to efficiencies that reduce the error rate.
Adelman and others set about studying the error rate from open charts, in a randomized clinical trial of ED, inpatient and clinic providers, published recently in JAMA. They used a clever proxy for wrong orders on patients, by looking at order sessions where an order was placed on a patient, canceled, and then placed on another patient within a few minutes.
The headline finding was that there was no clear relationship between the number of open charts and the error rate.
There are a lot of interesting little nuggets in the data, however. The overall ED error rate, for instance, was around 160 wrong order sessions out of 100,000 – that was less than most inpatient units (avg 185 wrong-patient order sessions per 100k). This was far less than the ICUs (~250 errors per 100k), but also far more than the outpatient clinics (~8 wrong order sessions per 100,000). There was no significant difference in the error rate when comparing the clinicians who were restricted to one chart, to clinicians who could open up to four charts.
In the ED and inpatient units where multiple charts were allowed to be open, significantly fewer wrong orders were noted when just one chart open was open. It’s an interesting wrinkle, but the effect wasn’t dose-dependent (for instance, more errors were observed in the ED with three charts open rather than four). And lots of docs in the “up to four charts” arm voluntarily limited themselves to one chart open at a time, which limited the comparisons that could be made.
I’d love to see breakdowns of training level (were errors regarding multiple charts more likely among interns, or older docs who didn’t grow up with computers?) but the paper didn’t delve into those subgroups.
Still, this paper’s primary conclusion holds: limiting docs to just one chart at a time didn’t reduce errors compared to those that were allowed up to four charts. This ought to be enough to take to your CMOs and IT leadership, if they’re insisting on curtailing your efficiency in the name of patient safety.
And really, IT leadership should know: If you want to reduce the rate of wrong orders on patients, don’t hamstring the docs. There are proven interventions, like including patient photos in the EHR, that will reduce wrong patient orders without curtailing efficiency.
And as the accompanying editorial by Bob Wachter and others noted: limiting the number of open charts probably hurts efficiency, and slows us down, which can introduce other kinds of errors and patient safety risks. These may be harder to measure, but they’re no less real.
Finally, it goes without saying (which is probably why so many administrators don’t say it), when it comes to improving patient safety, adequate staffing and support probably plays more of a role than any feature in the EHR.
Adelman JS et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial. JAMA. 2019 May 14;321(18):1780-1787.
Wachter, R et al. Restricting the Number of Open Patient Records in the Electronic Health RecordIs the Record Half Open or Half Closed? JAMA. 2019;321(18):1771–1773.