The Waste of Handwritten Notes


Nurse + Blog = PixelRN: 16% of the US economy runs on scrawly, handwritten notes.

PixelRN is a blog written by a nurse (who is unfortunately considering leaving the field). She writes about the problems involved with handwritten orders, charts, and notes that are used in so many hospitals. This is particularly a problem in hospitals without “electronic medical records” (computer systems that can be helpful, but they're also not the cure-all that vendors would claim — more on that later in this post).

Charting and records — that's an example of how quality and efficiency go together. EMR can be faster (but not always) and it can also help prevent errors or miscommunications. PixelRN writes:

I made a mistake yesterday. I didn't just miss one order. I missed A WHOLE PAGE OF ORDERS.

Why? Because the doctor wrote them on a separate page and stuffed them into the side pocket of the binder, rather than putting them in the proper place.

Here's a process error that could really impact that patient's care. Part way to a root cause, we could ask “why didn't the MD put the orders in the right place?” The RN probably just gets blamed for not finding them (and blamed for not reading the MD's mind). If we put an electronic system in, we still have to rely on people using it properly (assuming they're trained and they understand the implications of not following the standardized work). PixelRN again:

Fortunately no one was harmed, although the patient did have to stay in the recovery room for an additional hour because I didn't see the order.

This was my mistake and believe me, I owned up to it. I apologized to the patient for creating this delay and I apologized to the attending for missing his order, but I know that this mistake could have been avoided if the recovery room used a computerized ordering system.

Or if the MD had properly utilized the paper chart binder. Why is the RN apologizing?

She writes further:

And yet there is such a lack of standardization in the way that doctors write their orders, so it can be difficult to carry them out. Do the recovery room nurses care about this? The answer appears to be no. Whenever I ask the nurses about this situation their reply is this, “Oh we've been fighting this battle for years. Nothing ever changes.”

How do you get beyond that kind of apathy?

It requires Leadership! This isn't something that Lean can solve if there's not leadership and a drive to fix problems like this. It's so sad to hear about the frustration (and to see it first hand)

I've seen cases where a hospital HAD the electronic systems and they were used inconsistently. Some MD's refuse to use the Computerized Physician Order Entry Systems (CPOE). The electronic charting systems are often slow and glitchy, leading nurses to workaround the problem by writing down and carrying lots of paper notes around. So what was really solved?

I'd argue that hospitals need to focus on “process” as much as (if not more than) technology. Don't expect technology to be a cure-all, because it's not.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Hi Mark,

    you’re quite right Lean starts with LEADERSHIP!!

    Leaders set the space, tension and vision for growing their teammates towards lean thinking and continuous improvement.

    Leaders have VISIONS (necessary to get lean going) whereas managers just deal with current reality (establishing a comfort zone for everyone -especially themselves).

    This may sound a bit hars but that is what I have experienced in my almost two decades where I have had direct involvement in work processes.



  2. I’ve seen this exact thing when I worked in healthcare too. I went to do an ultrasound on the patient and I couldn’t find my written order. Turned out the unit clerk had entered the orders in the computer but then didn’t return the page to the binder — as a result he nurse had missed a whole page of orders.

    I only know my hospital, but I can’t understand how anyone can tolerate the amount of foolishness that goes on in our hospitals. They drive the best people out with incompetence.

  3. Leadership is the key. The big issue is “who’s in charge?” The administration? The doctor? The nurse manager? One issue that we face is competition for doctors – will they take their business to the other hospital? They’re treated more as a customer than a partner in many cases. This is one of the big barriers we must break down in order to make some of the key changes we need to make.


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