Computerized Charting Errors-Need Stories

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Hi Everybody!

I'm doing a presentation on pitfalls of electronic medical records, and I am focusing on errors unique to computerized charting that nurses need to actively protect themselves from. I could really use examples of errors, or near errors, by nurses that were made specifically d/t computerized charting. I can use personal examples or if you post links to internet articles that would be great too. If you give a personal example, I would appreciate it if you could include the city/state or hospital that it happened in and it would also help to know what happened to the nurse. Some of my subjects are: charting under someone else's name, med errors, issues with drop down menus, inaccurate charting d/t lack of appropriate choices, CPOE... anything along that line. I want this presentation to shed light on EMR issues/dangers that we may not even be aware of, so that we can protect ourselves. Any help is greatly appreciated!!!

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Specializes in Inpatient Oncology/Public Health.

I had a med error that was eventually linked back to a pharmacist. I had a patient come from the ED on a heparin drip. The paper flowsheets all said "standard dose WITH rebolus." The order in the system said the same. The pt's initial ptt called for a rebolus so I checked with a second RN, scanned the bolus and gave it. 24 hours later I had the same patient and noticed the order in the computer said NO rebolus. I was confused and called pharmacy who stated the rebolus order was discontinued IN the ED. My only previous med error prior to this was giving a whole vs half a Xanax and I was sick over it. I couldn't even see the electronic trail of all that had happened in the system and pharmacy seemed excited to throw me under the bus, telling the attending I had given the pt a bolus while the pt was therapeutic(not true, I gave a bolus when indicated, and the bolus was present in the PRN meds, was scanned with no warning popping up, etc.) After a full investigation it came out that pharmacy had changed the order while helping out the ED but had left the other order active, hadn't communicated the change to anyone, and had left the boluses in place in the PRN meds(which I think should drop out automatically when the order is changed from bolus to no rebolus instead of having to be taken out manually.) At first pharmacy had insisted a nurse had changed the order even though no nurse name was connected with the change, only a pharmacist. This resulted in reeducation for pharmacy. I think with such a high alert med some changes need to be made but it hasn't happened yet. This was in NY state. The patient was supra therapeutic but ended up being fine and going home. I ended up being essentially absolved but felt like a criminal who couldn't prove my innocence and diligence while it was going on. The way orders can be changed and removed in the electronic record was nerve wracking but ultimately I guess the trail was there that showed what really happened.

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Specializes in orthopedic/trauma, Informatics, diabetes.

i have seen a newborn charted as having a hx of gastric byass sx .

A temp. on a new admission-source: core brain temperature.

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Specializes in Emergency, Telemetry, Transplant.

On our VS flow sheet, under "delivery device" (for oxygen) there is a check box for "room air" list right next to "RAM cannula." I admit, it had to look up the latter…it seems like someone could click the wrong thing.

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Specializes in NICU, Trauma, Oncology.

Patient last name "Test" other departments constantly using said patient fir training because they think it's a test patient. Have had to correct info repeatedly and get special screen popup to ensure that user knows it is in fact a real patient not a training patient.

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Specializes in Heme Onc.

While I was a student in the ICU very recently I had a computerized medication mix up:

The computer system used at this particular hospital (I can PM you the hospital or Location, but will not advertise it publicly), uses Cerner/Powerchart, which requires a 2 -step login system. The user must first login to to the computer system and then login again to Cerner/Powerchart. They have eliminated the need to manually type both logins by allowing for users to sign up for badge scanning, that will sign in to both places at once. However, this commonly fails, and people will login to the system, only to actually get to Cerner and find that they're logged in as someone else.

During my clinical in the ICU and on a day that I was not scheduled to pass meds, and we were working with a patient who had severe PVD, with many arterial and venous stasis ulcers on his legs. These ulcers were very painful for the patient, and he would wail in agony (poor man :() at the mere thought of changing the dressings. The nurse and I noticed that he did not have adequate pain control, and asked a resident for premedication for his scheduled dressing change, and consult with plastics (who was consulted in conjunction with vascular to aid in his would healing.) The resident gave the nurse a verbal order for 1mg dilaudid IV push, but errantly entered the order as 10mg IV push (In what freaking world... seriously.) Before the nurse even collected and prepared the dilaudid, the resident realized their error and re-entered the order for 1mg IV push, they did not(or the computer did not) remove the order for 10mg IV push.

Heres where the med "error" happens. I was previously logged into the computer in the patients room, charting my assessment and other aspects of care (I had long since been logged out!). When the nurse entered the room to premeditate the patient she logged in to the system, scanned the 1mg dilaudid, gave it to the patient, and wasted the remaining dose with the charge nurse. BUUUUUUUUUT..... The corner system failed (yet again) and I was still logged into the system and the old 10mg order was still there. So in the end... it appeared as if a student (not scheduled to give meds) delivered a 10mg dose of IV dilaudid to a patient.

This mixup was noticed later that evening, by a clinician, who saw the whopping 10mg IV dose of narcotics not validated by my instructor. After some serious confrontation and coordination we were able to figure out what happened and that the patient received a safe dose of a drug from his assigned nurse... but the experience was very frightening, as all of it was done in my name!

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Thank you so much for your story. Your feelings of being a criminal are exactly why I am doing this presentation. Good nurses are being put into bad situations, and hopefully with more awareness about the risks and pitfalls of computerized charting, we can find new ways to safeguard ourselves. Thank you again for contributing!!

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Wow, that badge scanning sounds scary! One of my big focuses is charting under another person's name, and I can definitely see how this was VERY scary for you! Thank you so much for sharing this story! I hope that it will help other nurses protect themselves from these same circumstances.

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Thank you all for these contributions! Every little bit helps and I especially appreciate the personal stories- I know that they can be hard to tell. The errors that occur with computerized charting are all new to us and it's impossible to know what to look for to protect yourself, but these stories will help other nurses watch for similar situations, so THANK YOU!

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Specializes in Pediatric/Adolescent, Med-Surg.
Thank you so much for your story. Your feelings of being a criminal are exactly why I am doing this presentation. Good nurses are being put into bad situations, and hopefully with more awareness about the risks and pitfalls of computerized charting, we can find new ways to safeguard ourselves. Thank you again for contributing!!

Just curious but what are you trying to prove with this presentation? Most people are in favor of EMRs and you don't really hear much against them

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Specializes in psych, addictions, hospice, education.

I recommend not posting anything that has any identifying information in it, because that could risk your job, and might slide into a HIPAA violation or even some legal action by a patient, depending on what you write. Please be careful what you write in an online environment, since you never know who is reading!

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Specializes in ICU.

Day shift used to be especially bad about copying and pasting previous assessments without checking behind themselves. I am sure night shift did too, I just don't follow other night shift nurses so I haven't personally seen night shift do it. The number of times I would see ETT 22 cm right side on the 1500 assessment (and the 1100 assessment) when the nurse had charted that the patient was extubated at 0900 was ridiculous. These people ruined the system for the rest of us - management took away copy and paste after that. We use McKesson and charting a full assessment takes a while. I have been out more than an hour and a half late before just catching up on routine charting for two ICU patients. It is a shame management caters to the people who don't check behind themselves and penalizes everyone for a few people's mistakes.

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