RESEARCH Research and Practice Innovations
Diet Order Entry by Registered Dietitians Results in a Reduction in Error Rates and Time Delays Compared with Other Health Professionals Kristen Imfeld, RD; Mary Keith, PhD, RD; Linda Stoyanoff, RD; Heather Fletcher, RD; Sasha Miles, MEd, RD; Joan McLaughlin, MHSc, RD
In January 2009, registered dietitians (RDs) at St Michael’s Hospital (Toronto, Ontario, Canada) were granted approval for nonmedication order entry of physician-approved nutrition-related orders for the patients to whom RDs provided care. The aim of this project was to document any changes in the numbers and types of diet order errors and time delays that were associated with this policy change. A retrospective chart audit was conducted to document the error rate in 672 nutrition-related orders placed before, and in 633 orders placed after, implementation of RD diet order entry on high-risk inpatient units. Error rates for all nutrition-related orders decreased by 15% after RD order entry access (P⬍0.01). Error rates for diet orders entered by RDs were signiﬁcantly lower in comparison with those entered by clerical assistants or registered nurses (P⬍0.001). Time delays for orders electronically entered were reduced by 39% (from 9.1 to 5.7 hours; P⬍0.01). Allowing RDs access to the electronic order entry system has improved overall timeliness of nonmedication order entries and improved patient safety by decreasing error rates in diet orders. This study supports this institutional policy change and provides evidence that RDs have the knowledge and skills to accurately process nonmedication order entries for the patients they have assessed. Finally, the current ﬁndings support the need for ongoing education and training of all health professionals in nonmedication order entry to reduce errors and improve safety.
Accepted 7 May 2012 Available online 11 July 2012
Keywords: Time delay Registered dietitian Error rates Registered nurse Clerical assistant Copyright © 2012 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 doi: 10.1016/j.jand.2012.05.020
J Acad Nutr Diet. 2012;112:1656-1661.
HE USE OF HEALTH INFORMATION SYSTEMS (HIS), including computerized practitioner order entry and nonmedication order entry, has enormous potential to aid hospitals in achieving their strategic direction related to higher-quality patient care and improved satisfaction. Research over many years has shown beneﬁts and challenges with the use of electronic order entry systems in both academic and community institutions.1-6 Published studies have mainly focused on issues pertaining to physicians and registered nurses (RNs) and their use and views of the system, including time efﬁciencies,3,6,7 potential cost savings,1,5,6 and decreased medication errors.6,8-10 Unfortunately, very little data have been published about electronic diet order entry, and no studies have been conducted comparing the accuracy and efﬁciency of diet order entry of different health professionals. At a 575-bed acute care teaching hospital in Toronto, Canada, ongoing advances in the computerized HIS have occurred. In the development and implementation of the new HIS system, registered dietitians (RDs) were no longer able to execute or modify therapeutic diets in the computerized system. Subsequently, RNs and clerical assistants became the only staff authorized to access the diet order entry system. 1656
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
An internal audit completed in December 2006 identiﬁed that a substantial number of diet order errors were occurring with the order entry system. Although system changes were made, lingering concerns remained about the accuracy of diet order entry. Inaccurate diet orders place patients at risk of receiving incorrect and inappropriate food for their medical conditions or nutritional status and have the potential to negatively impact overall patient satisfaction. Therefore, through collaboration with the Clinical Dietetics Professional Practice Leader, RDs, Department of Professional Practice-Health Disciplines, Supply Chain and Food Services Department, and Clinical Informatics, RDs were given nonmedication order entry access for nutrition-related orders written with a physician co-signature starting in January 2009. The purpose of this study was to document the numbers and types of errors as well as the order transcription time delays that occurred in the period immediately before and after implementation of the policy allowing RD nonmedication order entry privileges. The aim of the study was to demonstrate that by allowing RDs diet order entry privileges for their patients, error rates and time delays would be reduced. It was hypothesized that a policy change facilitating RD electronic order entry would result in an 8% reduction in error rates. In addition, a reduction in time delays of 20% was predicted after RD order access. © 2012 by the Academy of Nutrition and Dietetics.
RESEARCH METHODS This was a retrospective, observational chart review with purposeful sampling conducted on high-risk inpatient units at St Michael’s Hospital (Toronto, Ontario, Canada). High-risk units were deﬁned as those with high error rates, high patient volume, use of enteral nutrition, and high-risk diets, such as dysphagia-related or renal restrictions. Assuming 300 new diet orders per week, data on error rates and time delays before implementation of the policy change were collected during the ﬁrst 2 weeks of December 2008. Data on error rates and time delays after RD diet order entry privileges were granted occurred during the ﬁrst 2 weeks of February 2009. During the two data-collection periods, a trained RD used census reports for all patient admissions to compare diet orders in the paper-based medical chart with those entered into the electronic system. The study team created standardized deﬁnitions of diet order errors to incorporate into a data-collection form and guide data entry. Diet order errors included: orders that were written in the chart but not entered into the HIS, orders entered into the HIS but not written in the chart, using the term diet as tolerated (unrecognized as a diet type at St Michael’s Hospital), inappropriate diet transition orders (upgrading from one diet to another without a new order), errors in transcribing the diet order from the chart into the HIS (missing part of an order), orders inappropriately written in the comments box when the drop-down diet selection tool was available, and inappropriate diet orders requested by using the free-text message area in the HIS. The professional designation (ie, registered nurse [RN], clerical assistant, or RD) of each person entering nutrition-related orders was noted, and when the designation was unavailable an investigator searched the online staff directory to determine whether the professional was an RN, clerical assistant, or RD. Patients without a written diet order in the medical chart and without a diet order entered electronically were excluded from the study. Diet order complexity was deﬁned as the number of individual order elements that comprised one patient’s diet order. For example, a “cardiac, diabetic” diet contained two diet order elements. The diet error rate per order was calculated by considering each diet order element individually and subtracting the number of element errors from the total number of diet order elements. The average of this error rate per order for all orders was subsequently assigned to the health professional that entered the diet order into the HIS. The delay in time between when a diet order was written in the chart and the time the order was entered electronically was documented. Data were collected and entered by one trained RD. Entered data were randomly veriﬁed by a second member of the study team. The study protocol received ethics approval by the hospital’s Institutional Research Ethics Board.
Statistical Analysis Sample size was based on an expected error reduction of 8% and 20% reduction in time delays after RD order entry access using data collected in the 2006 audit. A required sample size of 940 orders (470 orders before and after RD access) was calculated based on a 95% conﬁdence level and 80% conﬁdence interval width. Statistical analysis was conducted using the Statistical Package for the Social Sciences for Windows (version 16.0, 2009, SPSS Inc). An independent t test was used to evaluate parametric continuous variables. Individual errors October 2012 Volume 112 Number 10
were transformed into a dichotomous “error” variable (yes/ no) and were described using frequencies. Comparisons between both data-collection periods and between other categorical variables were examined using Pearson 2 test. Differences in error rates among health professionals were analyzed using one-way analysis of variance. If signiﬁcance was achieved at the Pⱕ0.05 level, individual comparisons were made using Tukey post hoc test. Time delays in order entry were highly skewed and were therefore analyzed using nonparametric statistics and presented as the median and 25th and 75th percentile. The KruskalWallis test was used to determine overall differences between the three health professionals entering orders. Pairwise comparisons were completed using the Mann-Whitney U test.
RESULTS A total of 1,305 nutrition-related orders were reviewed during the study period. Of these, 672 were orders placed before the policy change that allowed RD nonmedication order entry (December 2008) and 633 were placed after the policy change (February 2009). Eight clinical units had diet orders reviewed during the data-collection periods. The distribution of orders by clinical unit was as follows: gastrointestinal/general surgery (23.1%), general internal medicine (20.9%), medical/surgical intensive care unit (7.9%), neurosurgery/neurotrauma (17%), cardiovascular surgery (14%), nephrology (9.1%), and cardiology (8%).
Nutrition-Related Order Entry Errors Of the orders entered into the HIS, 57.7% were ordered by RNs and 42.1% were ordered by clerical assistants before RD access. After the policy change, 51.3%, 27.7%, and 18.7% of orders were entered by RNs, clerical assistants, and RDs, respectively. Before RD access to nonmedication order entry, 377 of the 672 orders reviewed contained at least one error, an overall error rate of 56%. After RD access, a signiﬁcant drop of 15% (P⬍0.01) was noted, with 259 of 633 (41%) orders containing one or more errors. Examining the types of orders revealed a signiﬁcant reduction in diet order errors (P⬍0.01). The frequency of individual types of errors before and after RD diet order entry is displayed in the Table. Four of the 10 types of errors showed a statistically signiﬁcant decrease in frequency after RD diet order entry, while six of these differences remained unchanged. Errors regarding improper transcription of orders from the medical chart into the electronic system decreased signiﬁcantly, by 8%, from 166 errors in December 2008 to 110 errors in February 2009 (P⬍0.01). Error rates involving incorrect terminology as well as the use of the free-text comments box and ordering via the message function were also signiﬁcantly lower after RD order entry (P⬍0.05). Supplement order errors decreased from 22 to 15 orders with one or more errors (P⫽0.15), and enteral nutrition order errors decreased from 24 to 14 with one or more errors (P⫽0.11), although these did not reach statistical signiﬁcance. In the period before the policy change, RNs and clerical assistants, respectively, demonstrated similar average error rates of 0.97⫾1.18 and 0.96⫾1.05 total errors per order. Diet order error rates made by RNs and clerical assistants after RD nonmedication order entry remained constant at 1.05⫾1.21 and 1.12⫾1.43 total errors per order. RD diet order error rates were signiﬁcantly fewer per order entered (0.26⫾0.62 total JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
RESEARCH Table. Error rates for speciﬁc diet orders before and after registered dietitian order entry access Before No errors
One or No more errors errors
One or more errors P value
4™™™™™™™™™™™™™™ n (%) ™™™™™™™™™™™™™™™3 Order not written in chart 597 (89) a
Order not entered in HIS
506 (75) 166 (25)
523 (83) 110 (17)
566 (84) 106 (16)
Supplement order error c
EN order error a
HIS⫽health information system. Order written in chart as “diet as tolerated” or DAT. c EN⫽enteral nutrition. b
Average Error Rate per Order
* P<0.01 *
2 RNa CA b RDc
1.5 1 0.5 0 Before
Figure 1. Diet entry error rates for all orders by health professionals. aRN⫽registered nurse. bCA⫽clerical assistant. cRD⫽registered dietitian. errors per order) compared with RNs or clerical assistants (P⬍0.001) (Figure 1). Diet order error rates had a direct and signiﬁcant relationship to the diet order complexity before and after RD diet order access (P⬍0.01). However, the smaller slope of the regression line demonstrates a reduction in the error rate after RD order access (r2⫽0.035 before RD access vs r2⫽0.05 after RD access).
Time Delay of Order Entry Fifty percent of all orders were missing the time entry and were excluded from time delay analysis. Of the remaining 558 1658
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
orders, 273 were from December 2008 and 285 from February 2009. Before RD order entry, median time delays for RNs and clerical assistants was 2.62 hours (0.83, 9.28) and 2.17 hours (0.73, 7.77), respectively (P⫽0.86). Differences in time delays between professionals were noted after RD order entry privileges. After the policy change, RNs and clerical assistants had a median delay of 2.42 hours (0.64, 5.87) and 2.35 hours (1.1, 5.4), respectively. RDs had a median time delay of 0.22 hours (0.1, 0.8), considerably different compared with RNs and clerical assistants (Figure 2). Overall, a 39% reduction in the average time delay after RD order entry access was noted, from 9.1⫾15.8 hours to 5.7⫾12.1 hours. October 2012 Volume 112 Number 10
* P<0.01 to RD
Time Delay (hour)
RN a CA b RD c
4 2 0 Before
Figure 2. Time delay between when the order was written in the chart and when the order was entered electronically by differing health professionals. aRN⫽registered nurse. bCA⫽clerical assistant. cRD⫽registered dietitian.
DISCUSSION This study was conducted to document the changes in diet order entry error rates associated with the implementation of a hospital policy allowing RDs to enter physician co-signed diet orders for patients they assessed into the HIS. This is the ﬁrst study to examine differences in the accuracy of electronic nutrition-related orders between health professionals and demonstrates that RDs are competent at entering diet, supplement, and enteral nutrition orders for the patients to whom RDs are providing care. After granting RDs access for nutrition-related orders of patients they had assessed, there was a substantial improvement in the overall accuracy of reviewed orders. Little difference in the error rates of RNs and clerical assistants between data-collection periods was noted, supporting the beneﬁcial contribution by RDs in transmitting accurate diet orders. RDs have historically been challenged by process inefﬁciencies that served as barriers to implementing their nutrition care plans.11 Unpublished work previously conducted in 2006 at St Michael’s Hospital demonstrated unacceptably high error rates associated with diet order entry into the HIS. Subsequently, changes were implemented to the format of the diet order template in order to improve order accuracy. However, there were lingering concerns over continued inconsistencies and high user turnover. The observed 15% reduction in order errors supports the institutional policy change allowing RD order access, while reinforcing that RDs have the professional knowledge to effectively manage complex diet orders and accurately utilize nonmedication order entry systems. Improvements in error rates were observed in 4 of the 10 error categories after RD order entry access. Diet order error rates that remained largely unchanged were those that were unlikely to be impacted by RD diet order access (eg, “diet as tolerated” orders). Errors related to the use of improper terminology as well as using incorrect message or comments areas for order entry were reduced substantially after RD order access. In addition, transcription error rates were also reduced substantially. It has been documented that electronic systems can contribute to a decrease in the number of errors made in transcribing orders12; however, previous studies have emphaOctober 2012 Volume 112 Number 10
sized that even with the best available system, order outcomes are dependent on the person entering the order.9 Although the use of a free-text ﬁeld is discouraged, it remains a necessary option for patients with complex diet orders that require additional modiﬁcations when all drop-down menu options have been utilized. When the free-text ﬁeld is used to write additional diet order information, whether appropriately or not, it then becomes the responsibility of the diet ofﬁce staff to interpret this extra text. Not only does this increase the potential risk for errors, but studies have noted that using the free-text ﬁeld can also negatively affect the efﬁciency of order implementation, as orders must be double checked.7,13,14 Ongoing evaluation of the impact of RD nonmedication order entry on error rates and safety outcomes represents an area for future research. In addition, evaluating the changes in order volumes and outcomes associated with the transition to a complete electronic health record in relation to order entry would also be an area for future investigation and could potentially highlight the important role of the RD in the management of diet orders. Patient safety has become a major focus for health care quality. Accreditation Canada has brought patient safety to the forefront by identifying it as one of the dimensions used to deﬁne the quality of health care services at an institution.15 Accreditation Canada noted that high-performing organizations focus on safety and prevention and that organizations can improve their quality of care by being more aware of safety issues.15 With the improvement in the error rate for all nutrition-related orders, patient safety may have been enhanced. It is important to note that some nutrition-related order errors have the potential to cause substantial harm and, therefore, every opportunity to minimize all error rates for nutrition orders should be considered. RDs are well positioned to take a leadership role in both the investigation and evaluation of the potential safety impacts of nutrition-related errors. This represents an important area for future research. In terms of clinical workﬂow, computerized order entry systems have been shown on many occasions to reduce time delays in orders,5,6 therefore improving overall efﬁciency of care. Time delays are also costly for foodservice operations JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
RESEARCH because of the need to divert personnel when a meal service time is missed. Before RD nonmedication order entry, the average time delay was unacceptably high (9.1 hours). This delay was reduced considerably, by 39%, after RD nonmedication order entry. The decreased time delay for orders entered by RNs and clerical assistants in February is likely explained by having RDs contribute to a portion of orders entered speciﬁcally for their patients. There is still much improvement required. It has been well documented that efﬁcient and effective nutrition interventions implemented in a timely manner can increase a patient’s nutritional status,11,16,17 potentially decrease length of stay,11,16-18 and positively affect overall costs.16-18 When a patient’s nutrition intervention is delayed, potential improvement is also delayed, while at the same time adding inefﬁcient processes and unnecessary costs. RDs are acutely aware of a patient’s possible deterioration in status when nutrition recommendations are delayed17,19 and strive to prevent this with rapid implementation of interventions. Research has also noted that delays and errors can negatively impact patient satisfaction. Patients are often aware of mistakes made, especially when the error involves their diet orders.20 Patients indicate that food served in a hospital should model a healthy diet and recognize when an incorrect food item is served and contradicts the RD’s recommendations. Negative incidents, including inappropriate time delays, can impact overall satisfaction, often causing patients to be more critical of other services provided.21 There were some limitations in conducting this study. As a retrospective study, it only allowed associations, not causations, to be examined. Some data were incomplete. Also, in 1% of the orders, the RD collecting data was unable to identify the person who entered the order as an RN, clerical assistant, or RD. It was possible that the professional was no longer employed at the hospital or was not included in the online staff directory. In addition, the small number of enteral and supplement orders likely limited our ability to observe a signiﬁcant difference in error rates. Because of technical differences between electronic order entry systems, the current results might not be generalizable to other institutions. Only one hospital was included in the current study. Workload as well as complexity and acuity of patients at this institution might have affected overall results and might not be comparable to other hospitals. Additional studies should be conducted to determine whether results would be consistent across hospitals.
tants. However, RNs and clerical assistants have multiple responsibilities, rapid turnover rates, and lack of continuity in the patients they are caring for, which makes achieving error rates similar to RDs, who follow the nutritional care of individual patients, challenging. This would be an interesting question to address in the future. In order to ensure appropriate use of resources and RD knowledge, institutions must continue to stress legitimate referrals for RDs and encourage education of all health professionals involved in diet order entry to improve overall error reduction and time delays. It is imperative that RD access to electronic diet order entry systems be promoted and supported in hospitals where these systems exist or are contemplated, as RDs are critical players in the advancement of patient care through the use of electronic HIS when used in combination with nutritional care.
Birkmeyer CM, Lee J, Bates DW, Birkmeyer JD. Will electronic order entry reduce health care costs? Eff Clin Pract. 2002;5(2):67-74.
Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
Mekhjian HS, Kumar RR, Kuehn L, et al. Immediate beneﬁts realized following implementation of physician order entry at an academic medical center. J Am Med Inform Assoc. 2002;9(5):529-539.
Weir CR, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: A systematic review and analysis of the quality of the literature. Int J Med Inform. 2009;78(6):365-374.
Niazkhani Z, Pirnejad H, Berg M, Aarts J. The impact of computerized provider order entry systems on in patient clinical workﬂow: A literature review. J Am Med Inform Assoc. 2009;16(4):539-549.
Gagnon M, Desmartis M, Labrecque M, et al. Systematic review of factors inﬂuencing the adoption of information and communication technologies by healthcare professionals. J Med Syst. 2012;36(1):241277.
Weiner M, Gress T, Thiemann DR, et al. Contrasting views of physicians and nurses about an inpatient computer-based provider orderentry system. J Am Med Inform Assoc. 1999;6(3):234-244.
Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-321.
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005; 293(4 Pt 1):1197-1203.
Wulff K, Cummings GG, Marck P, Yurtseven O. Medication administration technologies and patient safety: A mixed-method systematic review. J Adv Nurs. 2011;67(10):2080-2095.
Moreland K, Gotfried M, Vaughan L. Development and implementation of the Clinical Privileges for Dietitian Nutrition Order Writing program at a long-term acute-care hospital. J Am Diet Assoc. 2002; 102(1):72-74, 79-81.
Hoggle LB, Michael MA, Houston SM, Ayres EJ. Nutrition informatics. J Am Diet Assoc. 2006;106(1):134-139.
Helbig LD, Bald ML. Design and implementation of a computerized diet order entry system for a hospital. J Am Diet Assoc. 1990;90(1):93-95.
Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-556.
2009 Canadian Health Accreditation Report: A Focus on Patient Safety, Using Qmentum to Enhance Quality and Strengthen Patient Safety. Ottawa, ON: Accreditation Canada; 2009.
Somanchi M, Xuguang T, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-216.
Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Ader HJ, Van Bokhorst-de van der Schueren M. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005;82(5):1082-1089.
CONCLUSIONS Granting RDs access to electronic order entry resulted in a substantial reduction in error rates. In addition, there was a considerable decrease in the time delay of nutrition-related orders, potentially impacting patient safety and satisfaction with the care and services provided at the hospital. Finally, this study provided institutional policy makers at this hospital with evidence supporting the positive impact of allowing RDs access to nonmedication order entry for the patients to whom RDs provided care. The difference in error rates supports that RDs are qualiﬁed and knowledgeable at accurately entering diet orders for the patients they have assessed. Error rates for orders entered by RDs were approximately 20% of those from orders entered by either clerical assistants or RNs. It is possible that continued education and training would reduce error rates in orders entered by RNs and clerical assis1660
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
October 2012 Volume 112 Number 10
Neumayer LA, Smout RJ, Horn HG, Horn SD. Early and sufﬁcient feeding reduces length of stay and charges in surgical patients. J Surg Res. 2001;95(1):73-77.
Watters CA, Sorensen J, Fiala A, Wismer W. Exploring patient satisfaction with foodservice through focus groups and meal rounds. J Am Diet Assoc. 2003;103(10):1347-1349.
Braga JM, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc. 2006;106(2):281-284.
Tengilimoglu D, Kisa A, Dziegielewski SF. Measurement of patient satisfaction in a public hospital in Ankara. Health Serv Manage Res. 2001;14(1):27-35.
AUTHOR INFORMATION K. Imfeld is a clinical dietitian, Trillium Health Centre, Mississauga, Ontario, Canada; at the time of the study, she was a clinical dietitian, St Michael’s Hospital, Toronto, Ontario, Canada. M. Keith is the coordinator of nutrition and dietetic education/research and an associate scientist, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, and an assistant professor, Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada. L. Stoyanoff is an interim CBORD coordinator and H. Fletcher is manager of patient food services, St Michael’s Hospital, Toronto, Ontario, Canada. S. Miles is manager of academic affairs and a clinical dietitian, St Michael’s Hospital, Toronto, Ontario, Canada; at the time of the study, she was an interim professional practice leader⫺dietetics, St Michael’s Hospital, Toronto, Ontario, Canada. J. McLaughlin is retired; at the time of the study, she was chief supply chain ofﬁcer and director of support services, St Michael’s Hospital, Toronto, Ontario, Canada. Address correspondence to: Mary Keith, PhD, RD, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conﬂict of interest was reported by the authors.
FUNDING/SUPPORT There was no funding for this project. The project was supported by the Chief Supply Chain Ofﬁcer and Director of Support Services at St Michael’s Hospital.
ACKNOWLEDGEMENTS The authors would like to thank Donna Kwan, Sally Remus, Dan Cass, Kevin Taylor, Dana Whitham, and Gail Wilson for their contributions to the project.
October 2012 Volume 112 Number 10
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS