Frequency of test order errors

The volume and rates of errors for each of the three periods January to June of 2009, 2010 and 2011 is presented in Table 5. The 2009 period covers the period prior to the introduction of EMR. The total number of errors increased from 1772 in 2009 to 2282 and 2452 in 2010 and 2011 respectively. When measured as a rate per 1000 test order episodes, this resulted in rates of 9.66, 12.67 and 13.48, for 2009 to 2011 respectively. The error rate in 2010 was approximately 30% higher than it was in 2009. The vast majority of this increase in errors reported was accounted for by errors classified as “EMR test order problem” (n=280) and “No specimen received” (increase of 197). It is also possible that some of the errors recorded as “Other” (increase of 55) and “Test set” (increase of 15) contributed to this increase in error rate between 2009 and 2010. Thus the increase in errors across time is largely due to a new category of errors associated with the electronic ordering process.

Error Rate per 1000 Test Order Episodes (Number of Errors)
	Error Type	2009	2010	2011
IIMS related categories	Mislabelled specimen	0.32(58)	0.14(25)	0.20(37)
	Mislabelled specimen	0.36(66)	0.64(116)	0.78(142)
	Unlabelled specimen	1.75(321)	1.35(243)	1.64(298)
Efficiency and effectiveness categories	Accident to specimen	0.13(24)	0.11(20)	0.14(26)
	Insufficient specimen	0.23(43)	0.19(34)	0.24(44)
	Leaking specimen	0.20(36)	0.17(30)	0.23(41)
	Collection requirements not met	1.19(219)	1.23(221)	1.58(287)
	Unlabelled or no request form	0.03(5)	0.36(65)	0.27(49)
	Patient details problem	0.08(14)	0.08(15)	0.17(31)
	Unsigned request form	0.12(22)	0.01(2)	0(0)
	Test set	0.72(133)	0.82(148)	0.53(97)
	Other	0.09(17)	0.4(72)	0.67(122)
Errors that are attributable to changed work processes brought on by EMR	EMR test order problem	n/a	1.56(280)	1.45(263)
	No specimen received	4.44(814)	5.61(1011)	5.58(1015)
Total Error		9.66(1772)	12.67(2282)	13.48(2452)
Total Test Order Episodes		183495	180059	181892

Table 5. Comparison of the rates and frequencies with which each type of error was recorded, collapsed across Hospitals A, B, and C, before the implementation of EMR (Jan-Jun 2009) and after the implementation of EMR (Jan-Jun 2010 and Jan-Jun 2011).

A detailed breakdown of the types of errors recorded as “EMR test order problem” is shown in Table 6. It shows that, across all three hospitals, 66.72% of errors were related to an order erroneously handwritten onto an EMR test order form print-out. This type of error generally occurred when the ordering clinician sought to amend an existing electronic order by altering the print-out of the order rather than creating a new order within the EMR. That is, in these instances, the ordering clinician treated the print-out of the order as though it was itself the order, rather than as a token representing the EMR order. (See Appendix IV for an example of a print-out of an electronic order that was manually altered, classified as a “Handwritten request on an EMR order” error). A further 26.48% had no information and could not be further categorised; and 6.80% reported a variety of reasons related to EMR order number problems, duplicate forms and wrong types of EMR order. Further analysis of the CSR error log revealed that 418 (61.83%) “EMR test order problem” errors required laboratory staff to contact the clinician or ward to request corrective action for the problem (to get a new order form from the clinician/ward, or to get a signed test order form from the clinician/ward).

	Hospital
Error details	A	B	C	Total
Handwritten request on an EMR order	65.24% (n=274)	64.47% (n=49)	71.11% (n=128)	66.72% (n=451)
Order number problem (number filed, used, invalid or discontinued)	3.10% (n=13)	5.26% (n=4)	2.22% (n=4)	3.11% (n=21)
Multiple forms (2 forms, 3 forms) / Duplicate Forms	1.90% (n=8)	0% (n=0)	0% (n=0)	1.18% (n=8)
EMR order incorrect (swab instead of fluid, urine received for swab, etc)	2.86% (n=12)	2.63% (n=2)	0.56% (n=1)	2.22% (n=15)
Change of tests	0.23% (n=1)	0% (n=0)	0% (n=0)	0.15% (n=1)
Add-on test	0.23% (n=1)	0% (n=0)	0% (n=0)	0.15% (n=1)
No information provided	26.43% (n=111)	27.63% (n=21)	26.11% (n=47)	26.48% (n=179)
Total	420	76	180	676

Table 6. The types of errors described in the error details free text for errors classified as “EMR test order problem” for electronic test orders only, and the frequency and rate at which they were recorded (01/03/2010 – 09/10/2011).

Errors of the “EMR test order problem” category have repercussions for CSR workflow. This begins with the need for CSR to complete an entry into the computerised error log that is then followed up by a designated laboratory error “trouble-shooter” who contacts the ordering clinician for corrective action (see Appendix VI). This results in delays to the pathology testing process. Table 7 compares the median data entry time between test order episodes that had an “EMR test order problem” error and median data entry time for all test order episodes (test order episodes with, and without, and errors logged). The median data entry time was three minutes (60%) longer when an “EMR test order problem” error was logged compared to the median data entry time of all test order episodes. A large part of this time delay was accounted for by additional time required for data entry staff in the CSR to make an entry in the computerised error log. When taking into consideration the amount of time required for the “trouble-shooter” to contact the clinician or ward and for the latter to take corrective action, as shown in the Total Laboratory TAT section of Table 7, the median TAT was three hours (181 minutes; 220%) longer when a “EMR test order problem” occurred than for all test order episodes.

	EMR test order problem	All Test Order Episodes
Median Data Entry time (mins)	8	5
	Z=7.65, p<.001
Median Total Lab TAT (mins)	263	82.14
	Z=8.91, p<.001
Total Episode Count (n=)	174	124119

Wilcoxon signed-rank tests of significance
Table 7. Comparison of median TATs for test order episodes that resulted in an “EMR test order problem” tests and the median TAT for all test order episodes.

Our cross-sectional analysis compared the volume and nature of errors for paper and EMR orders. Table 8 details the volume and rates of errors for electronic orders and paper orders across the hospitals for the period 1 March 2010 to 9 October 2011. The table shows that EMR uptake, during the analysis period, for each of the hospitals was 68.92% at Hospital A, 32.28% at Hospital B, and 58.46% at Hospital C. When considering the overall error rates across all hospitals, the rate of errors per 1000 test order episodes for the three IIMS-related problems was consistently lower for EMR orders than for paper orders: 0.10 vs. 0.31 for “Mislabelled specimen” errors, 0.49 vs. 1.42 for “Mismatched specimen” errors, and 1.37 vs. 1.65 for “Unlabelled specimen” errors. Chi-square (χ2) tests of independence, shown in Table 8, revealed that these differences in rates were all significant (p<.001, p<.001, p<.01, respectively).

Error Rate per 1000 Test Order Episodes (Number of Errors)
	Hospital
	A		B		C		Overall
	EMR	Paper	EMR	Paper	EMR	Paper	EMR	Paper
EMR Uptake Rate (01/03/2010 – 09/10/2011)	68.92%		32.28%		58.46%		62.34%
Error Category	IIMS related categories
Mislabelled specimen	0.08 (23)	0.52 (41)	0.07 (3)	0.13(8)	0.16 (13)	0.17 (7)	0.10 (39)	0.31 (56)
							χ2=36.51, p<.001
Mismatched specimen	0.44 (126)	2.18 (172)	0.46 (19)	0.73 (44)	0.70 (55)	0.97 (39)	0.49 (200)	1.42 (255)
							χ2=141.18, p<.001
Unlabelled specimen	1.12 (324)	2.31 (182)	1.34 (55)	0.80 (48)	2.28 (180)	1.65 (66)	1.37 (559)	1.65 (296)
							χ2=7.16, p<.01
Efficiency and effectiveness categories
Collection requirements not met	1.03 (298)	1.70 (134)	1.37 (56)	0.53 (32)	2.63 (208)	2.15 (86)	1.37 (562)	1.41 (252)
Unlabelled or no request form	0.16 (47)	0.47 (37)	0.24 (10)	0.30 (18)	0.28 (22)	0.32 (13)	0.19 (79)	0.38 (68)
Patient details problem	0.05 (15)	0.28 (22)	0.42 (17)	0.33 (20)	0.10 (8)	0.15 (6)	0.10 (40)	0.27 (48)
Test set	0.45 (129)	1.03 (81)	0.54 (22)	0.40 (24)	0.96 (76)	0.75 (30)	0.55 (227)	0.75 (135)
Unsigned request form	0.00 (1)	0.01 (1)	0.00 (0)	0.03 (2)	0.00 (0)	0.07 (3)	0.07 (1)	0.07 (6)
Other	0.21 (60)	0.46 (36)	0.34 (14)	0.30 (18)	0.44 (35)	0.70 (28)	0.27 (109)	0.46 (82)
Accident to specimen	0.09 (26)	0.10 (8)	0.29 (12)	0.12 (7)	0.30 (24)	0.15 (6)	0.15 (62)	0.12 (21)
Insufficient specimen	0.08 (22)	0.05 (4)	0.15 (6)	0.05 (3)	0.66 (52)	0.45 (18)	0.20 (80)	0.14 (25)
Leaking specimen	0.06 (18)	0.18 (14)	0.56 (23)	0.08 (23)	0.67 (53)	0.12 (5)	0.23 (94)	0.13 (24)
Errors attributable to EMR work processes
EMR test order problem	1.45 (420)	1.44 (113)	1.86 (76)	0.35 (21)	2.28 (180)	0.90 (36)	1.65 (676)	0.95 (170)
No specimen received	7.05 (2040)	3.78 (298)	3.76 (154)	1.48 (89)	10.01 (791)	2.96 (117)	7.29 (2985)	2.82 (504)
Total Errors	12.27 (3549)	14.52 (1143)	11.40 (467)	5.63 (339)	21.47 (1697)	11.48 (460)	13.96 (5713)	10.85 (1942)

Table 8. Comparison of the rates and frequencies with which each type of error was recorded at Hospitals A, B, and C. (01/03/2010 – 09/10/2011.)