Way back in our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent” we described how healthcare workers employ workarounds that may make their work faster or easier but in doing so they defeat the intent of technologies to prevent errors and ensure safe patient care. In that column we focused on workarounds related to bedside medication verification (barcoding) systems.
Another common workaround is related primarily to the automated dispensing cabinet (ADC). A recent Pennsylvania Patient Safety Advisory reported on overrides related to ADC’s (Grissinger 2015). Grissinger reviewed 583 events reported to the Pennsylvania Patient Safety Reporting System over a 2-year period related to overrides. Though over three quarters of these reached the patient, harm occurred in only 0.3% of cases. Grissinger notes that 75% of overrides occurred with ADC’s, though overrides were also noted during CPOE or pharmacist order entry (12%) or barcoding (7.5%).
The most common ADC override was unauthorized medications (i.e. obtaining a medication for a patient without a prescribed order), followed by wrong patient events and wrong dosage form events. Over 30% of the unauthorized medication events involved high-alert medications. Of all the medications involved, antibiotics and opioids headed the list but of the high-alert medications, opioids, anticoagulants and insulin were most commonly involved.
Interestingly, ADC overrides were more common on medical and surgical units rather than ICU’s or the ER where you might expect more emergent situations to make them more frequent. Patients age 65 and older appeared to be disproportionately affected.
Grissinger notes that one critical element of the safety protections bypassed particularly via the ADC overrides is review by a pharmacist. He notes that most hospitals have lists of medications for which overrides in ADC’s are allowable (so nurses may remove drugs from the ADC for urgent situations). The logic is that certain drugs may be urgently needed and cannot wait for pharmacist approval. But he notes that removal of a drug from an ADC might be necessary under some conditions but not under others. Yet such “lists” don’t differentiate those conditions. Virtually all ADC’s today maintain “override logs”. These should be reviewed regularly for appropriateness and medication errors should be reviewed against these override logs as well.
What’s missing in the override logs is the reason for each override. You’ve heard us say over and over that identification of workarounds is important because there is virtually always a reason staff are using workarounds (i.e. a system issue). Therefore, review of the override logs is critical to identifying what circumstances are leading to use of those overrides and what system problems might need to be fixed.
Another common workaround getting lots of attention recently is copying and pasting. Almost all physicians copy and paste in the EMR, particularly when doing daily progress notes on inpatients. That’s because the key elements in a daily progress note are usually the same from day to day except that the data about each element may differ. For example, a progress note about a patient with an infection might begin with a comment about their maximum temperature (eg. Tmax = 38.6º), followed by comments about symptoms related to the infection, and results of lab or microbiology tests. So it would be common to copy yesterday’s progress note, paste it under today’s date and update the specific elements. But problems arise when a previous note is simply copied and no update is performed.
The same applies to use of templates or macros in the EMR. One account of the famous early case of Ebola in the US (Hawryluk 2016) notes that the ER physician used a template but failed to update that template with the current patient temperature. Ebola was thus not immediately considered and the patient was discharged.
Concerns about copy-and-paste issues began to appear in the early days of EMR’s. Veterans Affairs facilities had some of the earliest EMR’s and in 2003 Hammond and colleagues (Hammond 2003) reported on the prevalence and dangers of copy-and-paste. They noted that 9% of progress notes had some form of copied or duplicated text. While they noted most instances were benign, they found that “high-risk author copying” occurred once for every 720 notes, but one in ten electronic charts contained an instance of high-risk copying. This included introduction of misleading errors into the EMR that were potentially unsafe. They note how such errors then may get propagated through the EMR.
In a seminal paper on the benefits and dangers of copy-and-paste Weis and Levy (Weis 2014) pointed out that the issue is bigger than copy-and-paste and includes macros, templates, automated data importation, “copy note forward”, and other methods by which information might move from one place to another in the EMR. They called these methods collectively “Content-Importing Technologies (CIT)”. They noted that aside from the perceived efficiencies derived from use of CIT, there were other potential benefits. For example, data entered into specific fields through templates may help with clinical research and CIT might help track specific problems longitudinally in a complex medical record. CIT might also help with discharge summaries and discharge instructions.
But they then listed the potential dangers of CIT. Medication and allergy lists that were not reviewed with patients and updated could propagate errors. Symptoms or histories of present illness might incorrectly be attributed to different times. And the use of macros and templates for physical exams raised the question as to whether all elements of the physical exams really had been performed. They also cite the study by Singh and colleagues on diagnostic error in primary care (Singh 2013) that showed practitioners copied and pasted previous progress notes into the index visit note in 7.4% of cases and, of these cases, copying and pasting mistakes were determined to contribute to more than one-third (35.7%) of errors.
Weis and Levy also note the legal and regulatory dangers of CIT, noting that Medicare has stated it will be auditing for “cloned” documentation that might represent fraud and abuse.
Our January 12, 2016 Patient Safety Tip of the Week “New Resources on Improving Safety of Healthcare IT” cited an excellent contribution on patient safety problems related to healthcare information technology (IT) based on a review of malpractice claims (Graber 2015). One of the themes in the Graber study was that, largely because of cut-and-paste capabilities or ability to pre-populate data, incorrect information may be propagated in the medical record. For example, importing a previous medication list might include medications the patient is no longer taking. Or omission of a medication on a medication list may result in continued omission of that medication in the future. They also emphasized the well-known risks of overriding alerts and employing workarounds.
The problems related to “copy-and-paste” workarounds have become so prominent that ECRI Institute, in conjunction with multiple other patient safety organizations (Partnership for Health IT Patient Safety), recently came out with a toolkit for safe use of copy and paste (ECRI Institute 2016). This culminated in four safe practice recommendations:
The toolkit also notes that many templates have been created to prompt physicians to include elements needed to maximize billing. This (and other reasons for CIT) has led to chart “bloating” in which notes and other documentation lead to larger and larger medical records.
The Partnership toolkit is well referenced and has links to excellent resources. It provides sample policies and procedures, audit tools, education and training materials, checklists and good guidelines and action plans for how organizations should go about implementing the above recommendations.
Practices and organizations need to evaluate the workarounds (in barcoding, overrides, copy-and-paste, and others) that are occurring and potentially endangering patient care. They need to do risk assessments of such practices and implement the tools provided in some of the above mentioned resources.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Grissinger M. Medication Errors Involving Overrides of Healthcare Technology. Pa Patient Saf Advis 2015; 12(4): 141-148
Hawryluk M. Report highlights errors caused by copying, pasting in medical records. Houston Chronicle 2016; March 12, 2016
Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe BM. Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication. AMIA Annu Symp Proc 2003; 2003: 269-273
Weis JM, Levy PC. Copy, Paste, and Cloned Notes in Electronic Health Records: Prevalence, Benefits, Risks, and Best Practice Recommendations. Chest 2014; 145(3): 632-638
Singh H, Giardina TD, Meyer AND, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; 173(6): 418-425, published online February 25, 2013
Graber ML, Siegal D, Riah H, et al. Electronic Health Record-Related Events in Medical Malpractice Claims. Journal of Patient Safety 2015; Published Ahead-of-Print November 6, 2015
ECRI Institute. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. Accessed February 29, 2016