Providers do not verify patient identity during computer order entry.

Area of Science:

• Medical Informatics
• Patient Safety
• Human Factors Engineering

Background:

• Patient identification is a critical safety goal, requiring verification using at least two identifiers such as name, date of birth (DOB), or medical record number (MRN).
• Ensuring accurate patient identification is paramount to prevent medical errors and improve healthcare outcomes.

Purpose of the Study:

• To assess the frequency with which medical providers verify patient identification during computerized provider order entry (CPOE).
• To identify potential gaps in patient ID verification processes within CPOE systems.

Main Methods:

• A prospective study utilizing simulated scenarios and an eye-tracking device to monitor provider actions.
• Medical providers reviewed simulated patient charts and performed order entry tasks, unaware that patient ID verification was the primary focus.
• Scenarios included embedded patient ID errors (incorrect DOB, misspelled name) and potential ambiguities (duplicate last names).

Main Results:

• While 100% of providers correctly identified patients with duplicate last names, only 8% detected a DOB error, and 4% identified a misspelled last name.
• No participants used the medical record number (MRN) for verification before selecting a patient from an alphabetical list.
• Overall patient ID verification using two identifiers occurred in only 23% of instances before ordering tests.

Conclusions:

• Medical providers frequently fail to detect patient identification errors during CPOE.
• Infrequent verification of patient ID using two identifiers during CPOE poses a significant risk to patient safety.