{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,1]],"date-time":"2025-11-01T02:40:42Z","timestamp":1761964842527,"version":"3.37.3"},"reference-count":18,"publisher":"Oxford University Press (OUP)","issue":"5","funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2017,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>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.<\/jats:p>","DOI":"10.1093\/jamia\/ocw188","type":"journal-article","created":{"date-parts":[[2017,2,23]],"date-time":"2017-02-23T23:33:56Z","timestamp":1487892836000},"page":"958-963","source":"Crossref","is-referenced-by-count":12,"title":["Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy"],"prefix":"10.1093","volume":"24","author":[{"given":"Richard","family":"Schreiber","sequence":"first","affiliation":[{"name":"Holy Spirit\u2014A Geisinger Affiliate, Camp Hill, PA, USA"}]},{"given":"Dean F","family":"Sittig","sequence":"additional","affiliation":[{"name":"University of Texas Health Science Center at Houston\u2019s School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX, USA"}]},{"given":"Joan","family":"Ash","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, OR, USA"}]},{"given":"Adam","family":"Wright","sequence":"additional","affiliation":[{"name":"Brigham & Women\u2019s Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Partners HealthCare, Boston, MA, USA"}]}],"member":"286","published-online":{"date-parts":[[2017,2,16]]},"reference":[{"issue":"Suppl 1","key":"2020110612360454200_ocw188-B1","doi-asserted-by":"crossref","first-page":"S69","DOI":"10.1016\/j.ijmedinf.2008.07.015","article-title":"The unintended consequences of computerized provider order entry: findings from a mixed methods exploration","volume":"78","author":"Ash","year":"2009","journal-title":"Int J Med Inform"},{"issue":"10","key":"2020110612360454200_ocw188-B2","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1001\/jama.293.10.1197","article-title":"Role of computerized physician order entry systems in facilitating medication errors","volume":"293","author":"Koppel","year":"2005","journal-title":"JAMA"},{"issue":"4","key":"2020110612360454200_ocw188-B3","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1197\/jamia.M1740","article-title":"Comprehensive analysis of a medication dosing error related to CPOE","volume":"12","author":"Horsky","year":"2005","journal-title":"J Am Med Inform Assoc"},{"issue":"5","key":"2020110612360454200_ocw188-B4","first-page":"418","article-title":"The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records","volume":"20","author":"Sittig","year":"2014","journal-title":"Am J Manag Care"},{"key":"2020110612360454200_ocw188-B5","unstructured":"Office of the National Coordinator. SAFER Guides. https:\/\/www.healthit.gov\/safer\/safer-guides Accessed September 27, 2016."},{"key":"2020110612360454200_ocw188-B6","unstructured":"Office of the National Coordinator. SAFER Guides. System Interfaces, Recommendation 5 and 6. https:\/\/www.healthit.gov\/sites\/safer\/files\/guides\/safer_systeminterfaces_sg005_form.pdf). Accessed September 27, 2016."},{"key":"2020110612360454200_ocw188-B7","unstructured":"Office of the National Coordinator. SAFER Guides. 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