Digital Harm?

The patient’s transfer and medication reconciliation had been done twice – once by the attending physician and once by the specialist ordering an upgrade in acuity. As the nurses assessed the differences, they found themselves asking: Which one takes priority?

The interesting thing about this incident – a near miss because the nurses caught it in time to clarify with both physicians – is that there was not a category in the incident reporting system to indicate this type of event.

In fact, there were no digital incidents in the entire list of risk management error type categories.

Further, this error did not exist in paper charting because two providers could not write orders in one physical chart at the same time.

This error was specific to the electronic medical record, yet there was no way to report it.

It wasn’t just a medication error because no medications were given and the order set was comprehensive, including dressing changes, activity, therapy and a host of non-pharmaceutical orders.

It wasn’t just an ordering error because both providers had appropriate credentialing and authority to place the orders and they were not wrong to do so.

Rather, this this was a digital communication issue with the computerized order system that allowed duplication of a one-time-only transfer order set that confused the coordination of care.

You see, the system did not indicate when the transfer orders were completed to prevent duplicates, nor was there any indication that the transfer orders were open on two different computers, though these discoveries could have provoked unique system improvements to prevent future events.

Instead, a call was placed to the CPOE (Computerized Physician Order Entry) team, who congratulated the nurses for catching the error, and made a note in their daily report.

But no changes were made to the system without the accountability of an internal incident report.

Which begs the question: Today, in our technologically advanced healthcare environment, does your facility have incident reporting for digital harm events?