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ED Nurses Report Cumbersome Documentation for EHR Behavioral Flags

ED nurses said EHR behavioral flag documentation should be easier to complete and there should be more leadership follow-up after flagged incidents.

While emergency department (ED) nurses described EHR behavioral flags as helpful for clinician safety, improvements are needed to streamline the process from documentation to follow-up, according to a study published in JAMA Network Open.

Researchers interviewed 25 nurses at an academic, urban emergency department on workplace violence, safety, and patient care.

While flags provided staff with a useful warning, nurses called for greater consistency in the system-level response to a flagged event, specifically by those reviewing the documentation of an initial incident.

ED nurses also noted that a cumbersome documentation system for EHR behavioral flags creates a dangerous mechanism in which workplace violence is underreported and leaves staff, patients, and visitors at risk.

Further, nurses mentioned concern for the unintended consequences of introducing implicit bias into patient care through EHR behavioral flags.

While interview participants acknowledged that flag placement can be biased against individuals who use the ED frequently or patients with addiction, many perceived no association between the racial or ethnic identity of the patient and whether they received a flag.

However, others felt that race and ethnicity impact who receives a flag and what behaviors providers tolerate.

“For example, several described a greater tolerance for harassment and abuse from White patients by physicians, making them less likely to intervene or provide support to nurses,” the study authors pointed out.

Despite nurses’ varied perspectives on the relationship between race and EHR flagging in the study, previous research has revealed that Black patients disproportionately receive flags compared to White patients.

“As part of the expressed desire for better and more effective trainings to address workplace violence, these findings suggest that it would be worthwhile to include trainings that specifically address the relationship between racism and flags as well,” the study authors wrote.

The researchers suggested that a periodic review of patient behavioral flags and the utilization of a patient advisory board to provide policy guidance could help mitigate systemic racism related to flags.

Further research should explore what other procedures or policies, combined with behavioral flags, are most effective at reducing incidents of workforce violence in the ED, the authors noted.

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