AUTHOR BIOGRAPHIES
Sadaf Kazi, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Sadaf Kazi is a senior research scientist at the MedStar Health National Center for Human Factors in Healthcare and an associate professor at Georgetown University School of Medicine.
Jessica L. Handley, MA, MedStar Health National Center for Human Factors in Healthcare
Jessica L. Handley is the associate director of operations at the MedStar Health National Center for Human Factors in Healthcare.
Arianna P. Milicia, BS, MedStar Health National Center for Human Factors in Healthcare
Arianna P. Milicia is a senior research analyst at the MedStar Health National Center for Human Factors in Healthcare.
Raj M. Ratwani, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Raj M. Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.
Katharine T. Adams, MS, MedStar Center for Biostatistics, Informatics, and Data Science
Katharine T. Adams is a data scientist at the MedStar Center for Biostatistics, Informatics, and Data Science.
Rebecca Jones, MBA, RN, Patient Safety Authority
Rebecca Jones (rebejones@pa.gov) is director of Data Science & Research at the Patient Safety Authority.
*Corresponding author
Seth Krevat, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Seth Krevat is the senior medical director at the MedStar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.
Abstract
Background
When placing orders into the electronic health record (EHR), prescribers often use free-text information to complement the order. However, the use of these free-text fields can result in patient safety issues. The objective of our study was to develop a deeper understanding of the conditions under which free-text information, or special instructions, are used in the EHR and the patient safety issues associated with their use, through an analysis of patient safety event (PSE) reports.
Methods
We identified 847 PSE reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2021, and December 31, 2022; this dataset was reduced to 677 after controlling for oversampling from particular facilities. After limiting to reports that mentioned the terms “special instructions,” “order instructions,” “order comments,” or “special comments,” we analyzed a total of 329 reports. A physician and human factors expert independently reviewed the reports and assigned each a code from the following categories: general care process, medication class, information expressed in the special instruction, special instruction issue, department or staff for which special instruction was intended, and whether the error reached the patient.
Results
Almost three quarters of the special instruction reports were related to Medication (n=233 of 329, 70.8%), followed by Laboratory/Blood Bank (n=54, 16.4%), and Radiology (n=23, 7.0%). Medication classes most frequently associated with special instructions included infectious disease medications (n=51 of 230, 22.2%), antithrombotic/antithrombotic reversal agents (n=32, 13.9%), and nutritional/electrolytes/intravenous fluids (n=32, 13.9%). Nearly one quarter each of medication-related special instructions were about timing (n=58 of 233, 24.9%) and dosing (n=54, 23.2%); most about laboratory/blood bank were related to the site of the blood draw (n=33 of 54, 61.1%), and many involving radiology were related to radiology/echocardiography instructions (n=16 of 23, 69.6%).
The most frequent issues associated with special instructions were containing information contradictory to the order or other information (n=62 of 329, 18.8%); being confusing, incorrect, or used incorrectly (n=58, 17.6%); and not seen (n=25, 7.6%), not viewable (n=11, 3.3%), or instructions absent (n=11, 3.3%). In more than half of the reports, special instructions were intended for nursing staff (n=184 of 329, 55.9%), followed by pharmacy (n=49, 14.9%), radiology (n=21, 6.4%), and laboratory/blood bank (n=20, 6.1%). The error reached the patient in roughly three quarters (n=243 of 329, 73.9%) of the reports reviewed.
Conclusion
Special instructions are frequently used to provide additional context about medication orders and laboratory and radiology procedures and are often intended for nurses and pharmacists. However, these instructions can result in errors and may cause patient harm. Based on our analysis, we provide EHR design strategies and policies and protocols to address patient safety issues associated with free text to enable safer and more resilient care delivery.
