Intercepting wrong-patient orders in a computerized provider order entry system.

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Quality Improvement

Background:

• Wrong-patient orders are a significant patient safety concern in healthcare settings.
• Computerized provider order entry (CPOE) systems offer potential solutions for error reduction.

Purpose of the Study:

• To evaluate the short- and long-term effectiveness of a CPOE-based patient verification intervention.
• To assess the impact of this intervention on reducing wrong-patient orders in emergency departments.

Main Methods:

• A quasi-experimental study design with historical and parallel controls was employed across 5 emergency departments.
• A mandatory patient verification dialog within the CPOE system was implemented, requiring provider confirmation.
• The retract-and-reorder technique was used to estimate wrong-patient order rates before and after the intervention.

Main Results:

• Immediate implementation of the patient verification intervention reduced wrong-patient orders by 30%.
• This reduction was sustained over two years, with a 24.8% decrease compared to baseline.
• Providers spent an average of 4.2 seconds on the verification dialog, with longer times when errors were identified.

Conclusions:

• A CPOE-based patient verification system effectively reduces wrong-patient orders.
• The intervention demonstrated sustained effectiveness over the long term.
• Intercepting errors at the data entry point is a critical strategy for enhancing patient safety.