EHR "order fatigue" like "alarm fatigue"

[avado, BSN]

Has any one caught or have missed orders on CPOE nursing orders?

We have CPSI and our MAR is usually okay but Nursing orders can be overwhelming in our electronic MEDact (kardex). I had one patient with about 60 different nursing orders due to Standard order sets...PCA, POST OP, & CWAI.

RNs are the only set of eyes to figure the mess out (noting) and clean by date what is appropriate. It is usually the night RN since days do not have time for noting. The DR rarely DCs items in MEDact only Medications. UC job is not to sort the MEDact anymore like they use to. With a full patient load and a screen to scroll thru... these Orders are not going to implemented or noted in a timely fashion. Small important items like SCDs are missed mixed with various parameters....call dr if temp over 100.8...call dr temp over 102... call if systolic ... and yes three different ones... would you be fatigued!?

[dream'n, BSN, RN]

Hey I hear ya. Our nursing order area on the computer can be HUGE. Reason I always double check ALL orders on ALL patients on ALL shifts.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Just wait until you have a system that carries over a previous admission's orders into a current admission.

[HouTx, BSN, MSN, EdD]

YIKES! Are you (and your colleagues) making sure that the 'powers that be' understand the cumulative effects that you're describing? If you can't get them to listen, I would suggest tackling this as a performance improvement/safety issue. Keep going until you get someone to pay attention.... much better than uncovering it as part of a Root Cause Analysis subsequent to a sentinel event.

[avado, BSN]

Oh I agree. I have been a nurse 14+ years and did my round of chart checks. As a nurse, we always find errors in something that didn't get put on the MAR, MEDact, or have received the complete order dump from previous RN. This mess is still around but in greater numbers due to EHR orders which are out of site (out of mind) unless to click to note those orders. Seems like more my focus on basic charting assessments and scanning meds but no real time to verifying accuracy of orders as a unit clerk would do. I did get tangled in this mess and pointed it out to my manager and the CPSI order set person. I know for a fact the order sets are amended differently by doctors and some don't know how amend and hit you with the full crazy over kill (surgical order) set for a minor office procedure!

Yes the next step will be QI even though my manager butts heads with them. I worry about patient safety and will not brush errors off as some do. Appreciate the honest answers.

[dudette10, MSN, RN]

Is there a different way to look at orders so they are not such a mess? Many of colleagues look at orders through one screen, which includes all orders ever put in for a patient during a single admission (grouped and in reverse order with most recent on top), and I've often shown them the order screen I use. My order screen is "active orders only," and some have said, "I didn't know that was there!"

You still need to go to QI, but in the interim, check to see if there's an easier screen to read.

[calivianya, BSN, RN]

Oh, my job is like that, and they insist that only physicians add/remove orders. Yes, I'm serious. So those ten million orders from a pre-procedure set five days ago have to be d/c by a physician. Day shift is too busy to mark all of these orders for a physician to d/c, and I am pretty sure I would get cussed out if I called a physician at 0300 just to d/c old orders.

Oh, and speaking of alarm fatigue, this same job insists that we cannot change alarm parameters without a physician order. I can also only silence alarms for five minutes at a time. The same alarm will start alarming again after those five minutes are up. I literally have patients whose alarms are going off every five minutes for the same alarm I first noticed 20 minutes ago. I would probably also get cussed out for calling a physician so he/she could wake up, log into the computer, and write an order that it is okay to change an alarm parameter at 0300.

My management cares nothing about nursing workflow.

[avado, BSN]

Thank you dudette and calivanya. I voiced my frustration to the IT computer person(previous RN) since my manager is swamped to reply. Yes we have a nursing order screen that we can scroll thru but like i said it is huge and time consuming. Basically, I need to do what Calivianya does and call the doctor at 0300 to dc items off the nursing order and maybe the doctor will learn not to overkill us with those huge order sets.

Our QI sucks they drive our manager crazy and do not see what the nurses are going thru. They are for the administration to make sure the hospital gets their dollar. My two cents...