Understanding and preventing wrong-patient electronic orders: a randomized controlled trial
- Jason S Adelman1,2,
- Gary E Kalkut1,3,
- Clyde B Schechter5,6,
- Jeffrey M Weiss1,4,
- Matthew A Berger1,2,
- Stan H Reissman9,
- Hillel W Cohen5,
- Stephen J Lorenzen7,
- Daniel A Burack8,
- William N Southern1,2
- 1Departments of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 2Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 3Division of Infectious Diseases, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 4Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 5Departments of Medicine Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 6Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
- 7Boston College, Chestnut Hill, Massachusetts, USA
- 8Harvard University, Cambridge, Massachusetts, USA
- 9Emerging Health Information Technology, Bronx, New York, USA
- Correspondence to Dr Jason S Adelman, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA;
Contributors JSA and CBS had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: JSA, MAB, SHR, HWC, CBS. Acquisition of data: DAB, SJL, GEK, JMW, SHR. Analysis and interpretation of data: CBS, JSA, WNS. Drafting of the manuscript: JSA, WNS, CBS. Critical revision of the manuscript for important intellectual content: JSA, WNS, CBS, GEK, JMW, MAB, SHR, HWC, SJL, DAB. Statistical analysis: CBS, JSA. Obtained funding: GEK, JSA. Study supervision: JSA.
- Received 21 April 2012
- Accepted 4 June 2012
- Published Online First 29 June 2012
Objective To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study.
Materials and methods In phase 1, from May to August 2010, the effectiveness of a ‘retract-and-reorder’ measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an ‘ID-verify alert’, and an ‘ID-reentry function’.
Results The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71).
Discussion and conclusion Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.
Funding This work was supported by institutional funds from Montefiore Medical Center, and in part by the CTSA grant UL1RR025750, KL2 RR025749 and TL1 RR025748 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the NIH roadmap for medical research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of Montefiore Medical Center, the NCRR or the NIH. Montefiore Medical Center had no role in the design and conduct of the study; collection, analysis, or interpretation of the data; or preparation, review or approval of the manuscript.
Competing interests None.
Ethics approval Ethics approval was provided by Montefiore Medical Center institutional review board.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The dataset used for this study includes one entry for each order placed at Montefiore Medical Center from 1 January 2009 to 20 June 2011. Only study personnel (listed as authors) had access to the data. The data have not been shared with any other entity.