Report: Wrong-Patient Orders Occur Frequently with CPOE Systems

Hospitalist Jason Adelman, MD, MS, believes computerized physician order-entry (CPOE) systems improve workflow and help prevent many mistakes, but the automation also causes mistakes as physicians toggle back and forth between screens in the system interface.

Dr. Adelman, patient safety officer at Montefiore Medical Center in the Bronx, N.Y., and colleagues developed an automated method for measuring wrong-patient electronic orders. They found that systems that compel physicians to re-enter certain information reduced errors.

CPOE systems have "certainly prevented errors," he says, "but they’ve unintentionally caused errors, and the name of the game is to keep working on ways to prevent more and more errors and minimize those errors unintentionally caused by these systems."

The researchers hypothesized that some wrong-patient orders are recognized by the orderer shortly after entry, promptly retracted, then re-entered on the correct patient. Their study results, published in the Journal of the American Medical Informatics Association, used a "retract and reorder" measurement tool that flagged any orders placed on a patient that were quickly retracted and replaced with a new order set.

Using the tool, Dr. Adleman and his research team estimated that 5,246 orders were placed on the wrong patients in 2009 at Montefiore.

The study also showed that interventions helped lower the odds of wrong-patient errors. One method made physicians click on a link to verify a patient’s identity, while another required the physician to manually input information to confirm the patient’s identity. Potential other interventions included using photo identification to ensure that physicians entered orders correctly.

"I think the goal is to try to get perfection," Dr. Adelman says. "I don’t know if you could ever get totally there … but you try."

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