Abstract
Across various healthcare systems, serious patient safety issues occur where patients who express Do-Not-Resuscitate (DNR) wishes receive resuscitative measures in error. Our Patient Safety team conducted a common cause analysis and identified contributing factors to such errors, including the unclear display of patients’ code status in the electronic health record (EHR). Our team proposed updated wording for the code status in the EHR and evaluated the proposed design via remote usability testing. Eleven physician and nurse end users participated in 30-minute one-on-one sessions where they consulted EHR screens to respond to simulated patient emergency scenarios. All participants successfully interpreted the updated screens and responded positively to the changes. Following these results, a multidisciplinary team used a Failure Modes and Effects Analysis (FMEA) to guide the successful implementation of the updated design.
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