Default values in electronic health records pose patient safety and liability risks
Executive Summary
Default values that are programmed into electronic health records (EHRs) and computerized physician order entry (CPOE) systems can threaten patient safety. They can result in patients being administered wrong doses of medicine and other errors.
Default values must be changed when inappropriate for the patient, but can be overlooked.
Some systems will override a manual order entry with a default value.
Systems might inappropriately end prescribed therapy after a default time value.
With electronic health records (EHRs) and computerized physician order entry (CPOE) becoming more common in all healthcare settings, alarms are being raised about the potential threat to patient safety from default values embedded in the systems. Research is showing that patients can be harmed when the default values are not overridden when necessary.
Medication dosages pose the most risk from default values, says Rishi Agrawal, MD, a pediatric hospitalist at La Rabida Children’s Hospital in Chicago.
"Clinicians often tell you that these tools are a bit of a mixed bag," he says. "They certainly can improve your efficiency and quality, and they may remind you to do certain things that might have been lost before. But at the same time, there is the danger of putting some processes on autopilot and pushing through orders that you don’t actually want."
Recent research from the Pennsylvania Patient Safety Authority (PPSA) found that default values can be problematic in several ways. Default values for medication dosages is perhaps the most obvious usage, but electronic systems also incorporate defaults in other functions such as the time allowed before a drug order is canceled.
In the PPSA research, analysts identified 324 events related to EHR software defaults.1 The three most commonly reported error types were wrong-time errors (200), wrong-dose errors (71), and inappropriate use of an automated-stopping function (28). The three most commonly reported causes for the errors were failure to change a default value, user-entered values overwritten by the system, and failure to completely enter information, which caused the system to insert information into blank parameters. Analysts also noted nine reports indicating that a default value needed to be updated to match current clinical practice. (See the story below for more on the PPSA research. See the story on p. 139 for PPSA’s recommendations.)
The PPSA report should prompt concern, Agrawal says, but he also notes that it does not document how many times those same EHR and CPOE systems improved patient care, when they avoided errors by prompting the clinician for a proper value or overriding a mistaken entry.
The efficiency of default values and automation must be balanced with the need to protect patients, Agrawal says. Also, any hospital with residents or other trainees must learn to enter the proper values and not rely on the computer to do it for them, he notes. (See the story on p. 139 for more on striking the right balance.)
Agrawal’s hospital is addressing the risk of medication errors from default values. At La Rabida, the EHR and CPOE systems do not have medications completely defaulted in any order set.
"When we launch an order set, we do have a list of favorite medications that are available, but someone still has to go through the process of checking them and, in most cases, having to edit the information," he says. "As a general rule, I think it is problematic for an order set to have medications completely checked from the beginning when it is opened up."
- Sparnon E. Spotlight on electronic health record errors: Errors related to the use of default values. Pa Patient Saf Advis 2013 Sep; 10(3):92-95.
- Rishi Agrawal, MD, Pediatric Hospitalist, La Rabida Children’s Hospital, Chicago. Telephone: (312) 695-5753. Email: [email protected].
Default values can cause variety of trouble
Electronic health records (EHRs) and computerized physician order entry (CPOE) are intended to streamline routine functions such as ordering medication and reduce the opportunity for human error, but they can introduce their own errors sometimes, according to recent research from the Pennsylvania Patient Safety Authority (PPSA).
The group’s study found that default values can be problematic in several ways, primarily wrong-dose errors, wrong-time errors, and automated stops that cancel medication and therapy orders.
"Facilities may wish to pay particular attention to the types and sources of error identified in this analysis when considering their use of default values in order sets, including consideration of how users view and enter time information, periodic review and change management, and differentiation between information that is user-entered versus overwritten or populated by the system," the PPSA author wrote.
Of the 324 verified reports, 314 (97%) were reported as "event, no harm," meaning an error did occur, but there was not an adverse outcome for the patient. Another six (2%) were reported as "unsafe conditions" that did not result in a harmful event.
Two reports involved temporary harm to the patient that required treatment or intervention. These events were associated with, respectively, acceptance of a default dose of muscle relaxant (which was higher than the intended dose) and an extra dose of morphine due to acceptance of a default administration time (which was too soon after the patient’s last dose). Two reports involved temporary harm that required initial or prolonged hospitalization.
PPSA cites two incidents that illustrate the hazards of default values. In the first, a patient did not receive the ordered antibiotic after a default stop time automatically cancelled the order:
• [During the evening, a] patient was ordered [an antibiotic]. The order was entered [30 minutes later] with a 48-hour stop time [default]. The first dose was sent up at that time. The first dose was returned to pharmacy later that evening, and the next two doses were given as scheduled The order was not renewed, [it] fell off the profile, and no other antibiotics were ordered for the next two days. On [day three], the patient’s temperature spiked at 102.3. The physician was called and ordered the [antibiotic] to be continued.
In another report to the PPSA, clinicians said that a patient did not receive the ordered antidiuretic due to a miscommunication as to which caregiver would administer the medication. The default value in the CPOE system indicated that respiratory therapy was to administer the medication, but this information did not match the hospital’s clinical practice:
• DDAVP [antidiuretic] nasal spray was ordered bid [given twice that same day]. Multiple missed doses were noted on the MAR [medication administration record]. Physician questioned the [registered nurse] caring for the patient about whether the patient was receiving DDAVP as ordered, since sodium levels were increasing despite DDAVP bid and strict free-water restriction. Upon investigation, [it was] noted that five doses were not given. Upon further investigation, [it was discovered that the system] default order has the box checked for "per [respiratory therapy] protocol." Respiratory therapy does not administer this medication, despite the fact that this is the default order selection and the fact that it is listed "per [respiratory therapy] protocol" on the MAR.
The PPSA report is available online at http://tinyurl.com/defaulterrors.
3 tips for reducing risk from default values
The Pennsylvania Patient Safety Authority (PPSA) recommends these three steps for reducing the patient safety risk posed by default values in electronic health records (EHRs) and computerized physician order entry (CPOE):
• Wrong-time errors. To address wrong-time errors, facilities can pay particular attention to the manner by which time information is entered by users and the manner in which time information is relayed to users after selection. This step can include assessing how and whether a user can specify times for particular types of orders (medications, lab draws); implementing user training to ensure that users know the difference between selecting "stat" or "now" selecting a specific time, and accepting the next standard time for the administration or procedure; and ensuring that, after selection, the system clearly displays the selected time.
• Errors related to outdated values. To address errors related to situations in which default values have not kept up with changes in clinical practice, facilities can develop electronic health record (EHR) system maintenance policies that require periodic assessment of whether order sets and clinical decisions support current clinical practice, as well as change management procedures for updating these systems once gaps are identified.
• Errors related to system-entered information. To address errors such as default values that are written over user-entered information or inserted into incomplete entries, facilities can determine whether EHR software allows users to easily differentiate between user-entered data and system-entered data.
Choose systems that minimize default errors
The best time to minimize the risk from default values in electronic health records (EHRs) and computerized physician order entry (CPOE) might be when you are choosing the system you will buy or designing its variables.
Look for systems that are designed to make order entry as simple as possible for clinicians but without an overreliance on default values, suggests Rishi Agrawal, MD, a pediatric hospitalist at La Rabida Children’s Hospital in Chicago. The user interface for some systems can be very "click intensive" and require the doctor to repeatedly click on options and values when filling out an order. That requirement can lead the user to select the default value too often, just to speed the process, he explains.
"It can require a lot of scrolling and clicking, jumping back and forth between screens. Some entries are required, but you can’t figure out how to enter them, and it is not efficient at all," Agrawal says. "Sometimes that hassle factor can be enormously frustrating, so the temptation is very high to resort to these default values."
