Patient Safety Tip of the Week
August 1, 2017 Progress on Wrong
Patient Orders
As early as 2008 we
were concerned that wrong-patient errors might be more frequent as we began
implementing CPOE systems (see our
Patient Safety Tip of the Week for May 20, 2008 “CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?”) and we’ve
done multiple subsequent columns on errors in patient identification. We
outlined the many factors contributing to wrong-patient orders in that column
and in our Patient Safety Tips of the Week for July 17, 2012 “More
on Wrong-Patient CPOE” and January 19, 2016 “Patient
Identification in the Spotlight”.
In the latter
columns we noted some of the tools developed by Adelman and colleagues to
minimize the chances of such occurring (Adelman 2013). The
intervention tools they developed were simple yet elegant. The “ID-verify
alert” was triggered by opening an order entry screen and prompted the
physician with the patient name, gender and age and the physician was required
to acknowledge that was the correct patient before being allowed to proceed
with order entry. The “ID-reentry function” prevents the provider from
accessing the order entry screen until he/she re-enters the patient’s initials,
gender and age. These interventions were piloted in a randomized fashion. While
the “ID-verify alert” reduced errors by 16%, the “ID-reentry function” reduced
them by 41%.
And, of course, not all solutions are high tech. In our August 2015 What's
New in the Patient Safety World column “Newborn
Name Confusion” we discussed another study by Adelman and colleagues
in which they applied their “retract and reorder” (RAR) tool to assess the
impact of a change in naming conventions
for newborns (Adelman
2015). Hospitals need to create a name for each newborn promptly on
delivery because the families often have not yet decided on a name for their
baby. Most hospitals have used the nonspecific convention “Baby Boy” Jones or
“Baby Girl” Jones. A suggested alternative uses a more specific naming
convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to
this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was
used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after
implementation of the new more specific naming protocol were 36% fewer than in the year prior to
implementation.
Now a new study in
NICU patients has demonstrated that these interventions, applied serially, have
indeed had a positive impact on reducing wrong-patient errors (Adelman
2017a). At baseline, wrong-patient
orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs
74.9 per 100,000 orders, respectively). Over a 7-year study period there was a
substantial reduction in the error rate. After implementation of the ID reentry
intervention, errors in the NICU were reduced to 60.2 per 100,000. The combined
ID reentry and distinct naming interventions yielded an additional decrease to
45.6 per 100,000 (a 61.1% reduction from baseline).
The study confirms
this combination of hi-tech and low-tech interventions has had a dramatic
impact on wrong-patient errors. Congratulations to Adelman and colleagues, who
have been pioneers in the charge to reduce such errors.
We should also
mention here yet another recent contribution by Adelman and colleagues
regarding wrong-patient errors. We’ve always contended that one of the biggest
risk factors for wrong-patient orders is having medical records of more than
one patient open at a time. Adelman and colleagues (Adelman
2017b) recently found in a survey of 167 inpatient and outpatient
facilities using EHR systems designed to open multiple records at once, 44.3%
were configured to allow ≥3 records open at once (unrestricted), 38.3%
allowed only 1 record open (restricted), and 17.4% allowed 2 records open
(hedged). Hence, there is yet no consensus on how to best address this issue.
Some CPOE systems
might be able to prevent you from having two patient records open at the same
time but some CPOE systems still have limited integration with other systems, such
as a radiology PACS system. It is not uncommon for a physician to look at
information on that other system while trying to input orders into the CPOE
system. Since they are two different systems, it is possible to be looking at
two different patients in the two systems. You therefore need to ensure that
when the physician moves between these two systems the same patient must be
visible on each system. That means you need to develop a way to launch the
other application and port the patient identification information to the other
application. We concur with Adelman and colleagues that this is an issue
demanding consensus and there is a need for more clearcut
guidelines.
Some of our prior
columns related to identification issues in newborns:
November 17, 2009 “Switched
Babies”,
December 20, 2011 “Infant
Abduction”
September 4, 2012 “More
Infant Abductions”.
December 11, 2012 “Breastfeeding
Mixup Again”.
April 8, 2014 “FMEA
to Avoid Breastmilk Mixups”
August 2015 “Newborn
Name Confusion”
January 19, 2016 “Patient
Identification in the Spotlight”
July 19, 2016 “Infants
and Wrong Site Surgery”
Some of our prior
columns related to patient identification issues:
May 20, 2008 “CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?”
July 17, 2012 “More
on Wrong-Patient CPOE”
June 26, 2012 “Using
Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic
Identification to Prevent Errors”
August 2015 “Newborn
Name Confusion”
January 12, 2016 “New
Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient
Identification in the Spotlight”
References:
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and
preventing wrong-patient electronic orders: a randomized controlled trial. J
Am Med Inform Assoc 2013; 20(2): 305-310 Published online 29 June 2012
http://jamia.oxfordjournals.org/content/20/2/305
Adelman J, Aschner J, Schechter C,
et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015;
Published online July 13, 2015
http://pediatrics.aappublications.org/content/early/2015/07/08/peds.2015-0007.full.pdf+html
Adelman JS, Aschner JL, Schechter
CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient Orders in
the NICU. Pediatrics 2017; 139(5): e20162863
Adelman JS, Berger MA, Rai A, et al. A national survey
assessing the number of records allowed open in electronic health records at
hospitals and ambulatory sites. JAMIA 2017; published online 17 April 2017
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