Healthcare systems face innumerable challenges to patient safety on a daily basis. Medical records, whether electronic health records (EHRs) or paper- based, represent an area where the need for confidentiality, standardization, reliability, appropriate infrastructure, information security and interoperability, ease of access, and portability can contribute to potentially dangerous conditions for a patient (Coombs, Stowasser, Reid, & Mitchell, 2009; Littlejohns, Wyatt, & Garvican, 2003; Mc- Donald, 1997; Rodriguez-Vera, Marin, Sanchez, Borrachero, & Pujol, 2002; Singh, Servoss, Kalsman, Fox, & Singh, 2004; Wears & Berg, 2005). Highly sensitive medical information may be inadvertently released or stored under an incorrect patient identifier, and proprietary health record mechanisms may improve intra-institutional operations at the expense of easy transfer of critical information across healthcare provider groups or networks. The application of human factors engineering (HFE) could mitigate some of these issues (Carayon, 2007; National Committee on Vital and Health Statistics, 2001).
One specific healthcare area for HFE investigation and intervention is the physical patient chart. Still a substantial component of medical records (as opposed to full EHRs) as reported by Jha and colleagues (2009) and Saleem et al. (2009), chart-holding binders, clipboards, folders, and related items for clinical paperwork ac- Key Words: Documentation, equipment design, healthcare quality improvement, human engineering, medical records cess and storage present an under-recognized hazard to patient safety (see Figures 1 and 2). Within this context, chart systems may benefit from HFE-based reorganization to mitigate risk to patients. Simple error-proofing of HFE interventions, such as the selective use of text fonts and sizes with prominent labeling (Wiklund, 2002), pre-implementation use-testing (Gosbee & Gosbee, 2007), cognitive and workplace walkthroughs (Khajouei, de Jongh, & Jaspers, 2009), clinical provider focus groups (Weingart et al., 2009), and the institution of fail-safe measures (Kaye & Crowley, 2000) can potentially enhance patient safety in clinical environments. Additional benefits may include increased healthcare provider efficiency, job satisfaction, and medical system efficacy.
Study investigators proposed the Emergency Unit Chart Localization, Identification, and Differentiation (EUCLID) project to (1) assess specific elements of the physical charting system in place at the study institution emergency department (ED) with respect to their potential for contributing to medical error, (2) implement an alternative charting system addressing specific human factors issues, and (3) evaluate the new system's effect on the chart-related potential for medical error in the ED.
The study was conducted at a 719-bed regional referral center and Level 1 trauma center located in the northeastern United States. The facility has more than 188,000 outpatient visits, 11,000 inpatient surgeries, and 143,000 ED visits (adult and pediatric) annually. The adult ED was constructed in 2005 and features six clinical care units: Critical Care Rooms (CCRs) with six rooms for 12 high-acuity patients; two Urgent Care A and B pods with 32 patient spaces (and seven additional spaces to be opened at times of increased ED census); 14-bed Fast Track C pod (two additional spaces); 19-bed Behavioral/Substance Abuse D pod; and seven-bed Chest Pain Observation Unit (CPU) space. Information for each individual ED patient is kept in an ED-specific medical record (ED chart) that houses all paper-based ED physician patient care documentation; prior medical records, radiographic studies, and the order entry system are accessed online. Each ED chart contains a patient registration sheet, physician documentation (T sheets® from T-System, Dallas, TX), and miscellaneous clinical paperwork (e.g. …