Gov't report finds small but real danger in EHR default settings

Good catch by EMR Daily News: A State of Pennsylvania agency report shows that EMR default settings can have  dangerous results.

The Pennsylvania Patient Safety Authority investigated EHR events related to defaults – that is, figures and instructions the systems automatically put in their fields when the practitioner fails to do so -- reported through the state’s mandatory reporting system between 2004 and 2013, and revealed its findings in a September 10 advisory.

The good news is that 97% of these events led to “no harm,” says the result. But there were some “temporary harm” events – for example, 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).”

And in one case, a default medication stop cancelled an antibiotic order the physician wanted continued, causing the patient to become feverish and the doctor to be called in.

Overall the Authority identified errors involcing wrong time, wrong dose, and wrong route (e.g., intramuscular, oral, intravenous), and suggested that facilites:

•  “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”;
• “develop EHR system maintenance policies that require periodic assessment of whether order sets and clinical decisions support current clinical practice”;
• “determine whether EHR software allows users to easily differentiate between user-entered data and system-entered data.”