Preventing Wrong-Patient Electronic Orders in the Emergency Department

Despite the effectiveness of this system in reducing the rate of near-miss wrong-patient orders in the ED, errors still occur. It is possible that providers are entering the patient’s initials and year of birth without carefully verifying the patient’s identity [9].The CPOE double ID system alert is about three-quarters the size of the monitor screen. Thus, the clinician is able to verify the patient’s initials and year of birth using the patient’s header on the screen behind the patient identification alert. If the provider simply types the initials and year of birth on the patient’s header, then an identification error can occur.

More work is needed to decrease CPOE-related patient identification errors. Possible improvements may include single sign-ons and a no-interruption policy when writing orders. During our investigation, it was found that some clinicians would have multiple EHR sign-on sessions open at one computer terminal. These multiple EHR sign-on sessions were sometimes the root cause of a wrong patient error. With multiple sign-on sessions open, clinicians could toggle back and forth between patients on the same computer terminal and mistakenly complete an order on the wrong patient.

No-interruption zones and policies have been proven to be an effective way of decreasing interruptions and enhancing safety during medication preparation [13,14]. Utilization of no-interruption zones for CPOE may also be effective. Potentially, the EHR background color could change when a clinician selects the “enter order” tab within the EHR. The new background color would signify to those around the clinician that he/she is not to be interrupted during that time.

After the success of this initial quality improvement project in the ED, the intensive care unit has been added as a location for the CPOE double identification system. The data and results for this phase of the project are being tabulated and seem promising. In addition, SBH Health System is exploring single sign-on software to both help clinicians provide service and enhance patient safety.

Corresponding author: Daniel Lombardi, DO, 4422 Third Ave., Bronx, NY 10457.

Financial disclosures: None.