Reducing Emergency Department Charting and Ordering Errors with a Room Number Watermark on the Electronic Medical Record Display
This is a review for Loren G Yamamoto’s Reducing Emergency Department Charting and Ordering Errors with a Room Number Watermark on the Electronic Medical Record Display. 
A survey of Emergency Department (ED) clinicians conducted to assess the frequency of errors in charting, and entering orders on the wrong patients chart in the electronic medical record, and clinician opinion was sought on whether a simple watermark of the patient’s room number might help reduce the number of these EMR “wrong patient errors. Would a room number watermark be an effective strategy to reduce wrong patient errors in charting?
Emergency Department clinicians using an electronic medical record.
During calendar year 2012, attending general emergency physicians, attending pediatric emergency physicians, ED nurses, and ED clinical assistants were asked in person to participate in a voluntary survey as a study subject. Participant responses were collected in person by the study investigator after verbal consent was obtained. The survey recorded the number of years of clinical experience of the study subjects. Nurses and clinical assistants were asked to approximate the number of hours worked during the previous 3 months. Physicians were asked to approximate the number of patient encounters during the previous 3 months. The different responsibilities of the physicians, nurses, and clinical assistants required the protocol to assess errors within their scope of respective responsibilities. The survey asked study subjects if they had ever made an error in which charting or order entry (physicians only) was done in the wrong patient's chart. The survey then asked study subjects for an approximate number of times this occurred in the last 3 months. Nurses were also asked if they noticed an ordering error (made by the physician) on the wrong patient's chart and to approximate the number of times this occurred in the last 3 months.
Study subjects were then shown the standard EMR screen (what they normally see), then an identical EMR screen with room number watermarks added to the patient chart and tabs. In addition, a verbal description of how the two screens differed was provided. Subjects were asked if they thought that the addition of the room number watermark and the room number on the tabs could potentially reduce the number of wrong patient charting/ordering errors. If they responded yes, then they were asked whether they thought this would eliminate just a few, roughly half, or most of the errors.
Data from each study subject survey form was manually entered into a spreadsheet (Microsoft Excel, Microsoft Corporation, Redmond, WA). Descriptive statistics were tabulated using the built-in functions of the spreadsheet.
A charting error was defined as key stroke into a note on the wrong patient's chart, even if the error was then discovered immediately and the note was purged. An ordering error was defined as entering an order on the wrong patient even if it was discovered immediately and the order was cancelled. Ordering error counts were defined in terms of episodes rather than the actual number of orders. For example, if a physician ordered three medications on the wrong patient at the same time, this was considered to be one error episode.
Of the 68 clinician study subjects who completed the survey, all but two (both were clinical assistants) had made a wrong patient charting or ordering error. Six (25%) of 24 physicians reported never making a wrong patient charting error, but 100% noted one or more wrong patient ordering errors (although not necessarily in the most recent 3 month study period). The highest numbers of wrong patient errors reported by physicians were 6.7, 10, 13.3, and 20 errors per month, respectively (one physician each) during the previous 3 month period. Other than these four physicians, total physician errors in the previous 3 months ranged from zero to 3.3 errors per month. Overall, the 3 month self-reported mean error rate was 4.8 per month (median: 1.7 errors per month). Total nurse errors ranged from zero to 1.7 errors per month in the past 3 months (zero to 2.8 errors per 100 hours). Most (97%) of the 31 nurses reported noticing wrong patient ordering errors by physicians, with observed error rates ranging from zero to 3.3 errors per month during the past 3 months (zero to 2.1 errors per 100 hours). Total 3-month error rates among clinical assistants also ranged from zero to 3.3 errors per month with a mean of 0.9 errors per month (median: 0.7 errors per month).
Of the 68 clinician study subjects surveyed, all except one felt that the room number watermark would reduce the number of wrong patient errors. The majority (81%) of the 68 clinicians surveyed felt that the room number watermark would eliminate most of the wrong patient errors.
Charting on the wrong patient and order entry on the wrong patient type errors are relatively common and occur with varying frequencies amongst ED clinicians. Nearly all the clinicians believe that a room number watermark might be an effective strategy to reduce these errors.
The results of the survey indicated that nearly 100% of clinicians made wrong patient EMR errors (charting and ordering) at some point with an average of 9.5 errors in the past 3 months suggesting that these errors are common.
The findings of this study confirm that ED clinicians who are routine users of the system believe that improving the information display in a way that heightens awareness of the most commonly utilized ED patient identifier (the room number) would be an effective means of reducing wrong patient errors. The room number watermark can be built into the EMR to display automatically and passively without clinician intervention. Other options to enlarge the room number would reduce the available screen display area, whereas the watermark method makes the room number very prominent without compromising screen display availability. In doing so, it could save time by avoiding the need to undo the error and then to repeat the task in the correct patient's chart.
More more information view the history of the EMR
- Yamamoto, LG. Reducing Emergency Department Charting and Ordering Errors with a Room Number Watermark on the Electronic Medical Record Display. Hawaii J Med Public Health. 2014 Oct;73(10):322-8. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/25337450