Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

Area of Science:

• Health Informatics
• Patient Safety
• Electronic Health Records

Background:

• Wrong-patient electronic orders are a significant patient safety concern in healthcare.
• Computerized physician order entry (CPOE) systems aim to improve medication safety but can introduce new error types.
• Estimating and preventing wrong-patient orders within CPOE systems requires robust evaluation methods.

Purpose of the Study:

• To evaluate methods for estimating the frequency of wrong-patient electronic orders.
• To assess the effectiveness of electronic interventions in preventing wrong-patient orders within CPOE systems.

Main Methods:

• A two-phase study was conducted, first validating a 'retract-and-reorder' tool to estimate error frequency.
• Phase 2 involved a randomized controlled trial to test 'ID-verify alert' and 'ID-reentry function' interventions.
• The 'retract-and-reorder' tool identified wrong-patient orders by tracking promptly retracted and reordered prescriptions.

Main Results:

• The 'retract-and-reorder' tool demonstrated a positive predictive value of 76.2% for identifying wrong-patient orders.
• An estimated 5246 wrong-patient electronic orders occurred in 2009 across four hospitals.
• The 'ID-reentry function' intervention significantly reduced the odds of wrong-patient orders (OR 0.60) compared to the control group.

Conclusions:

• Wrong-patient electronic orders are a frequent issue in CPOE systems.
• Electronic interventions, particularly the 'ID-reentry function', are effective in mitigating these patient safety risks.
• Further implementation of such electronic safeguards is recommended to enhance patient safety.