Safety of Electronic Documentation

xoemmylouox, ASN, RN · Jun 28, 2013

Scary stuff.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Jul 2, 2013

My issue is with physicians entering orders into the computer AND on the charts. With one eye glued to the computer so nothing is missed and the other glued to the chart so nothing is missed, who's gonna watch the patients???? Last week, a physician wrote an order on a chart at 1710 and placed the chart WHEREVER, but not in the rack for new orders.

Needless to say that when I got report from the day nurse, she was unaware of those orders because she couldn't find the chart. The patient situation was different from what was on the chart because the physician had come in, removed some things from the patient, and had not told the nurse. We finally located the chart around 2045. So I checked the ENTIRE chart for other orders to be carried out. (Patient has orders for discharge the next day. Ok, no problem. At least we know the deal now. So I proceeded to do the 2100 med pass. When I finally got a chance to do the official chart check, it was 0130 because of admissions, two very needy patients in a group of six, and I made number 7 who had to go to the darn restroom, too, but hadn't had a chance to go since BEFORE I clocked in at 1830.

Anyway, during the chart checks, the SAME doctor went elsewhere in the hospital, pulled up that SAME patient's electronic record, and entered NPO after midnight orders for surgery in early AM. WHAT!??!?! REALLY?!??!!! What happened to the discharge orders?????? That is a very important change and a huge leap in the plan of care which should have at least deserved a phone call, you think????

We have a list of physicians who are 'resistant' to computer entry, so we know that when we see those physicians or their representatives, to go check the chart. But these others are like loose cannons randomly firing off orders verbally, handwritten in the chart, and when they tire themselves out, they roll over and enter them in the computer. There is no end and LOTS of orders are being missed because of this. At some point, we as nurses have to stop checking for orders and actually go DO the work ordered. They don't seem to understand THAT little detail!!!! :madface:

xoemmylouox, ASN, RN · Jul 6, 2013

My issue is with physicians entering orders into the computer AND on the charts. With one eye glued to the computer so nothing is missed and the other glued to the chart so nothing is missed, who's gonna watch the patients???? Last week, a physician wrote an order on a chart at 1710 and placed the chart WHEREVER, but not in the rack for new orders.
Needless to say that when I got report from the day nurse, she was unaware of those orders because she couldn't find the chart. The patient situation was different from what was on the chart because the physician had come in, removed some things from the patient, and had not told the nurse. We finally located the chart around 2045. So I checked the ENTIRE chart for other orders to be carried out. (Patient has orders for discharge the next day. Ok, no problem. At least we know the deal now. So I proceeded to do the 2100 med pass. When I finally got a chance to do the official chart check, it was 0130 because of admissions, two very needy patients in a group of six, and I made number 7 who had to go to the darn restroom, too, but hadn't had a chance to go since BEFORE I clocked in at 1830.
Anyway, during the chart checks, the SAME doctor went elsewhere in the hospital, pulled up that SAME patient's electronic record, and entered NPO after midnight orders for surgery in early AM. WHAT!??!?! REALLY?!??!!! What happened to the discharge orders?????? That is a very important change and a huge leap in the plan of care which should have at least deserved a phone call, you think????
We have a list of physicians who are 'resistant' to computer entry, so we know that when we see those physicians or their representatives, to go check the chart. But these others are like loose cannons randomly firing off orders verbally, handwritten in the chart, and when they tire themselves out, they roll over and enter them in the computer. There is no end and LOTS of orders are being missed because of this. At some point, we as nurses have to stop checking for orders and actually go DO the work ordered. They don't seem to understand THAT little detail!!!!

What a nightmare! They need to have either EMR or paper charts. Having both puts patients at serious risk as with this example. Good Lord. Are there plans to transition to all EMR say in the next year or two?

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Jul 6, 2013

That's where the fun comes in.....we already have, with the above being the ending result!!!!!

Guests · Jul 6, 2013

Are EMRs perfect? Nope.

However, they're not replacing perfection.

That's why we have nurses as the final fail-safe... "Um, Doc, did you really mean to order ___?" or "Doc, should we consider adding ___?"

nowim clean · Jul 10, 2013

What the facilties need to do is put their foot down and tell the physicians if you are going to practice here you will put 100% of your orders into the computer unless it is a code or we will deny your privilges. If all hospitals would do this the docs would quickly get on board. Money is a great motivator.

MunoRN, RN · Jul 11, 2013

I don't think there's really any arguing that CPOE and EMR's are far safer than our soon-to-be-former system. There are going to be issues with the transitional period we're currently in, which is why many facilities are skipping the phase in of CPOE and going straight to 100% compliance. And there are some bad EMR systems out there, although with requirements that EMR's be "certified" in coming years this should help weed out the bad ones.

We had a sentinel event a few years ago where a patient on a PH drug was given nitro, they died. Recently we had another patient who came into the ER with chest pain and was about to be given Nitro, until the computer system refused to dispense the med since it knew the patient was on a PH med. There is also no "losing the chart" or missing orders that were written long ago (there is also no more need to check the transcription of orders). McDonalds has been using computerized order entry for almost 20 years, I think it's a little embarrassing that we're only now getting around to it.

Guests · Jul 12, 2013

there are some bad EMR systems out there, although with requirements that EMR's be "certified" in coming years this should help weed out the bad ones.

Unfortunately, some of the certified programs are still horribly difficult to work with and so create this massive distraction for the users or prevent the users from easily following what's going on with a patient.

Hopefully the market will take care of these companies but their terrible products will be entrenched in small organizations that cannot afford to replace them.

MunoRN, RN · Jul 12, 2013

Unfortunately, some of the certified programs are still horribly difficult to work with and so create this massive distraction for the users or prevent the users from easily following what's going on with a patient.
Hopefully the market will take care of these companies but their terrible products will be entrenched in small organizations that cannot afford to replace them.

You're right that the 'first wave' of meaningful use requirements hasn't filtered out some of the under-performing programs, but as the requirements become more stringent in the coming years many of those won't make it. Carecast for instance, a horrible program, barely made the first round of requirements but likely won't be around after the 2016 requirements get phased in (and actually probably won't even make it until then as it's users are quickly switching to other products).

Guests · Jul 12, 2013

I guess it's wait-and-see.

I used NextGen (lousy) and HMS (beyond horrible) before moving to Epic.

That my hospitals were duped into buying either of the first two is a sad testament to how woefully unprepared are many smaller facilities to undertake tech acquisition projects.

Epic, while having its issues, is actually a useful tool that enhances patient care rather than detracting from it.

allnurses Guide · Jul 13, 2013

It seems to me that many of the problems are due to lack of preparation and training. I also think additional staff should be scheduled until the staff and physicians are competent in the use of the system.

I quoted part of an article:

In over 100 reports submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe.
Patient care concerns included computerized delays in timely administration of medications and contact with physicians, ability to properly monitor patients, and other delays in treatment.
Many noted that the excessive amount of time required to interact with the computer system, inputting and accessing data, sharply cuts down on time they can spend with patients with frequent complaints from patients about not seeing their RN.
"EPIC is a system that is so cumbersome to use for nurses and physicians, that we often feel as though we are caring for a computer, not a patient," said Thorild Urdal, an RN at Alta Bates Summit's hospital in Berkeley. "It delays care and treatment, the program is naturally counter-intuitive and it was clearly not designed in concert with nurses and physicians." ...
... At Alta Bates Summit specific incidents directly related to Epic problems included:
A patient who had to be transferred to the intensive care unit due to delays in care caused by the computer.
A nurse who was not able to obtain needed blood for an emergent medical emergency.
Insulin orders set erroneously by the software.
Missed orders for lab tests for newborn babies and an inability for RNs to spend time teaching new mothers how to properly breast feed babies before patient discharge.
Lab tests not done in a timely manner.
Frequent short staffing caused by time RNs have to spend with the computers.
Orders incorrectly entered by physicians requiring the RNs to track down the physician before tests can be done or medication ordered.
Discrepancies between the Epic computers and the computers that dispense medications causing errors with medication labels and delays in administering medications.
Patient information, including vital signs, missing in the computer software.
An inability to accurately chart specific patient needs or conditions because of pre-determined responses by the computer software.
Multiple problems with RN fatigue because of time required by the computers and an inability to take rest breaks as a result.
Inadequate RN training and orientation. ...
http://www.enewspf.com/latest-news/health-and-fitness/44286-sutter-s-new-electronic-system-causes-serious-disruptions-to-safe-patient-care-at-e-bay-hospitals.html