How does one manage risk when writing orders is done by multiple healthcare providers, or as some risk managers call it “too many cooks in the kitchen?” 

“The subject of conflicting orders in a medical chart is a modern one,” said Timothy R. Bone, president of Florida-based MedMal Direct Insurance. “Up to the 1950s, the medical chart in the primary care setting was used as a reminder system for one physician to provide continuing care to a patient or his family. All the family records were simply kept in one physical chart and only one healthcare provider made entries in that chart. Even in the hospital setting, all consultants weren’t allowed to enter an order into the medical record; rather, they were required to communicate with the house physician or the attending physician, who then entered the order into the medical record. Oh, how things have changed!”

Authors of a study conducted in the 1980s expressed great surprise to find that as many as nine different physicians were involved in writing orders for one patient during a single 24-hour period. In today’s medical environment, this behavior has multiplied exponentially as other healthcare providers – nurse practitioners, physician assistants, nurse anesthetists, nurse midwives, and more – write orders in the medical record.

The solution, Bone pointed out, is to minimize but not necessarily eliminate multiple healthcare provider orders in the medical record.

The review procedure involves obtaining a sample of 50 charts of recently discharged patients, preferably including at least 10 patients who have been in the Intensive Care Unit (ICU) or the Coronary Care Unit (CCU).

“Review the order sheets – no more than three pages per chart – for the total number of healthcare providers who are actually writing orders, as well as the total number of orders written,” said Bone. “Calculate the mean (average) number of healthcare providers per chart and the total number of orders per chart, and then calculate the number of orders per healthcare provider. Review all of the charts for potentially conflicting orders where more than three ‘authors’ have contributed, or where the average number of orders per ‘author’ is less than five.” 

If all is in order, the action plan should include notifying the Medical Executive Committee and the medical staff at the next meeting.

“If problems exist, devise solutions and discuss them with your Medical Executive Committee and the medical staff,” he said. “After a consensus has been achieved, implement the solution, with appropriate publication to the people who will be affected by it. As always, re-audit the issue within a given time frame and report to the Medical Executive Committee and the medical staff with your updated status report.” 

An added point of emphasis: The old rule concerning the etiology of medical malpractice lawsuits still applies, that 50 percent of all communication problems arise from human interaction, 30 percent arise from system errors, and 20 percent arise from actual clinical malpractice, said Bone. 

“By simply minimizing the number of authors in the medical record of a single patient, the frequency and severity of iatrogenic injury – and the subsequent medical malpractice litigation – can be decreased,” he said. 

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