SHM Converge Scientific Abstract ePoster Gallery-Propagation of an Insidious Error Through an Ehr Documentation Shortcut

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This case describes how an EHR documentation shortcut (“dot phrase”) caused a widespread patient-safety problem. A hospitalist clinical coordinator noticed repeated patient calls after discharge, all linked to the same incorrect instruction containing the hospitalist clinical coordinator’s phone number instead of an appropriate service contact. Investigation showed that the number had been embedded in a custom dot phrase originally created by an internal medicine resident and later copied and shared widely across users outside the hospitalist service. The error had propagated through the EHR to 96 users initially, and an expanded search found 277 additional dot phrases containing the same number across 350 user accounts.<br /><br />The team reviewed possible fixes, including messaging all services, contacting users directly, deleting affected dot phrases, removing only the phone number, or replacing it with correct contact information. Each option had drawbacks, including delayed correction, disrupted workflows, or users failing to notice the change. After consulting hospital leadership, the team chose the least disruptive and safest solution: replace the hospitalist phone number in the affected dot phrases with a central hospital call center number designed to handle post-discharge questions.<br /><br />The authors conclude that documentation shortcuts improve efficiency but can also spread errors rapidly when shared and adapted across settings. This case is notable as the first known example of a dot phrase created for one context being widely reused in another, leading to incorrect patient instructions and potential harm. It highlights the importance of hospitalists in identifying EHR-related safety issues and designing practical interventions before further harm occurs.

Asset Subtitle

Kai Xu

Meta Tag

Author List Joel Betesh, John McGreevey, Kai Xu

Category Innovations

Concept EHR Documentation Shortcut

Concept Documentation Errors

Concept Patient Safety Risk

Concept Contact Information

Concept Discharge Instruction

Distinguished Non-Finalist

Presenter Organization Penn Medicine

Presenting Author Kai Xu

Track Patient Safety

Keywords

EHR documentation shortcut

dot phrase

patient safety

incorrect discharge instructions

hospitalist

electronic health record

shared templates

workflow error

post-discharge calls

central call center

EHR Documentation Shortcut

Documentation Errors

Patient Safety Risk

Contact Information

Discharge Instruction