Minimizing electronic health record patient-note mismatches

J Am Med Inform Assoc. 2011 Jul-Aug;18(4):511-4. doi: 10.1136/amiajnl-2010-000068. Epub 2011 Apr 12.

Abstract

We measured the prevalence (or rate) of patient-note mismatches (clinical notes judged to pertain to another patient) in the electronic medical record. The rate ranged from 0.5% (95% CI 0.2% to 1.7%) before a pop-up window intervention to 0.3% (95% CI 0.1% to 1.1%) after the intervention. Clinicians discovered patient-note mismatches in 0.05-0.03% of notes, or about 10% of actual mismatches. The reduction in rates after the intervention was statistically significant. Therefore, while the patient-note mismatch rate is low compared to published rates of other documentation errors, it can be further reduced by the design of the user interface.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Documentation*
  • Electronic Health Records*
  • Humans
  • Medical Errors / prevention & control*
  • Organizational Case Studies
  • Quality Control
  • United States
  • User-Computer Interface*