ArticleJournal of the American Medical Informatics Association : JAMIA2017
Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.
Article in Journal of the American Medical Informatics Association : JAMIA, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
6 citing papers in PubMed.
- A scoping review of rule-based clinical decision support malfunctions.Journal of the American Medical Informatics Association : JAMIA · 2024Article
- Impact of computerised provider order entry on the quality and quantity of clinical information included with investigation requests: an interrupted time series analysis.BMJ open quality · 2023Article
- Nurse workarounds in the electronic health record: An integrative review.Journal of the American Medical Informatics Association : JAMIA · 2020Review
- Smashing the strict hierarchy: three cases of clinical decision support malfunctions involving carvedilol.Journal of the American Medical Informatics Association : JAMIA · 2018Article
- Adherence to recommended electronic health record safety practices across eight health care organizations.Journal of the American Medical Informatics Association : JAMIA · 2018Article
- Unintended adverse consequences of a clinical decision support system: two cases.Journal of the American Medical Informatics Association : JAMIA · 2018Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors.
Funding
Abstract
In this report, we describe 2 instances in which expert use of an electronic health record (EHR) system interfaced to an external clinical laboratory information system led to unintended consequences wherein 2 patients failed to have laboratory tests drawn in a timely manner. In both events, user actions combined with the lack of an acknowledgment message describing the order cancellation from the external clinical system were the root causes. In 1 case, rapid, near-simultaneous order entry was the culprit; in the second, astute order management by a clinician, unaware of the lack of proper 2-way interface messaging from the external clinical system, led to the confusion. Although testing had shown that the laboratory system would cancel duplicate laboratory orders, it was thought that duplicate alerting in the new order entry system would prevent such events.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.