Preventing Wrong-Patient Electronic Orders in the Emergency Department

Journal of Clinical Outcomes Management. 2016 December;December 2016, Vol. 23, No. 12:

December 5, 2016|Journal of Clinical Outcomes Management

Daniel Lombardi, DO;Jacqueline Gaston-Kim;David Perlstein, MD, MBA;Ann Marie McDonald, EdD, RN;Kathleen McAuliffe, MS, RN;Jeffrey Lazar, MD, MPH;Eric C. Appelbaum, DO;Zane Last, PharmD;Renee C. Hulen, RN, BS-HCA

From SBH Health System, Bronx, NY.

Abstract

Objective: To decrease the number of near-miss wrong-patient orders in a computerized physician order entry (CPOE) system.
Methods: A CPOE alert was built that prompted the ordering clinician to reaffirm the identity of the patient by entering the patient’s initials and year of birth prior to placing an order. We used a retract and reorder tool to measure the frequency of near-miss wrong-patient order errors before and after implementation of the alert.
Results: The ID reentry function decreased near-miss wrong-patient orders in the ED by 35% during the 8-week pilot period. The system was also successful in helping to decrease the percentage of all CPOE near-miss events by 49%.
Conclusion: An alert that requires the prescriber to enter the patient’s initials and birth year is effective in decreasing wrong-patient orders in the CPOE system.

Key words: CPOE, near miss, patient safety, medical errors, wrong-patient errors.

Computerized provider order entry (CPOE) systems are commonly used to place orders. CPOE has been shown to reduce errors [1–4]. However, medication errors also can be caused or exacerbated by the CPOE system [5–7]. One type of error that can occur is placing orders on the wrong patient [8]. Wrong-patient CPOE errors can lead to significant morbidity and mortality [8–11]. To reduce wrong-patient CPOE errors in our health system, we developed an alert that required the ordering clinician to verify the identity of the patient. In this paper, we describe our project and outcomes attained.

Methods

Setting

SBH Health System is a not for profit health system located in Bronx, New York. The SBH Health System also has academic affiliations, and AOA and ACGME residency and fellowship programs. St. Barnabas Hospital, SBH Health System’s acute care facility, is a safety net hospital, Level 1 trauma center, primary stroke center, and STEMI receiving center. St. Barnabas Hospital has 422 licensed beds and had a total of 91,476 emergency department visits in 2015. The electronic health record in use at the time of the project was Allscripts 6.1. The Allscripts product, including its CPOE functions, has been in use in the SBH emergency department (ED) since 2011.

Review of Current Process

A team of multidisciplinary stakeholders was assembled comprised of hospital senior leadership, ED leadership, and front-line staff. Representatives from all disciplines involved in the CPOE process were invited, including nursing, pharmacy, radiology, clinical laboratory, and information technology.

A review was conducted of the CPOE ordering process. First, a fishbone diagram was created that identified contributing factors to the problem of CPOE patient identification error (Figure 1). Interruptions, multiple log-ins into the EHR, and the lack of an active patient identification process were found to be repeated contributing factors leading to CPOE ID/wrong-patient errors.

Next, we assessed our current error rate using a “retract and reorder” tool, which flags orders that have been placed for one patient, then erased and added to another patient’s file by the same clinician within a 10-minute time frame [8]. This tool, developed by Adelman et al, picks up near-miss errors, self-caught by the provider before causing harm [8]. Safety research has demonstrated that near-miss errors share the same causal pathway; therefore, measuring and preventing near-miss wrong-patient errors should reduce related errors that reach the patient.

For the period October–December 2014, we tabulated 231 near-miss wrong-patient orders that occured throughout the health system, of which 37% occurred in the ED. This translated to about 1 near-miss event per day in the ED. Given this data, the ED was the location for our quality improvement project.

Intervention

We implemented an ID reentry function in the CPOE system that prompts the prescriber to enter the patient’s initials and year of birth at the beginning of the order entry session (Figure 2A). This active double identification system is in line with the Joint Commission’s National Patient Safety Goal of using at least 2 patient identifiers when providing care, treatment and services. If the prescriber correctly inputs this data, then the ordering process can proceed. If the data is incorrect, then a second alert is activated (Figure 2B), allowing for correction of typographical errors that may not be related to an actual patient ID error. If at this point the prescriber enters the correct patient identifier, then he or she can proceed normally with the order. However, if the prescriber enters the wrong patient information again, a third and final alert is generated (Figure 2C). The EHR system recognizes this 2nd patient ID error as a true error and will not allow the prescriber to proceed with the order.

Outcomes

After a beta testing period of 1 week, the system was implemented on 3 November 2015. To assess the effectiveness of the alert system to prevent ordering errors, we used the retract and reorder tool to measure the rate of wrong-patient order entries for the 8-week period November–December 2015 and compared this with the preimplementation rate. Prior to the intervention, the average number of wrong patient order entries in the ED was 6.125 events per week. After implementation, the average number decreased to 4 events per week, a 35% decrease, and the proportion of near-miss ID errors in the ED relative to all such errors within the health system decreased from 37% to 19%.

References