Study: Wrong-Patient Orders With CPOEs Frequent But Preventable

Researchers at Montefiore Medical Center in New York City found that wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring, according to a recent study published in the Journal of American Medical Informatics Association.

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The study aimed to evaluate systems for estimating and preventing wrong-patient electronic orders in CPOE systems. There were two phases to the study. In the first phase, the frequency of wrong-patient electronic orders in 2009 was tested with a measurement tool in four hospitals. In phase two, a randomized controlled trial was conducted to evaluate the efficacy of interventions to prevent these errors. The interventions involved an “ID-verify alert” and an “ID-reentry function.” Wrong-patient electronic orders were defined as orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient

Results from the study include:
• The tool found an estimated 5,246 electronic orders that were placed on wrong patients in 2009, across the four hospitals.
• The interventions reduced the odds of a wrong-patient order event by about 95 percent.

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