June 26, 2012
Using Patient Photos to Reduce CPOE Errors
When we were involved in a CPOE implementation in 2008 we speculated that wrong patient errors would be more likely to occur via CPOE than conventional written orders (see our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences: Are Wrong Patient Errors More Common?”). We discussed the need to clearly identify patients on all order entry screens. Then in our January 12, 2010 Patient Safety Tip of the Week “Patient Photos in Patient Safety” we discussed patient photographs as potential tools in patient safety as a concept that had attracted surprisingly little attention to date. We’ve often thought that inclusion of patient photographs would be a logical tool to use in avoiding wrong patient surgeries or mixups in medication administration. And we were surprised to see that many hospital electronic medical record programs lacked standardized fields for such photographs.
In that column we did note some programs that successfully used patient photographs to reduce the risk of patient misidentification during medication administration (AHRQ Health Care Innovations Exchange). But there have been few other published accounts of use of photographs in the patient safety literature.
Recently, Children’s Hospital of Colorado published results of their successful implementation of patient photographs to reduce CPOE errors (Hyman 2012). Beginning with a nice review of the literature on patient-note mismatches, they implemented tools to help avoid such mismatches during CPOE. First they modified their CPOE workflow to include a verification screen asking the provider to verify that this is the patient on whom he/she intends to enter orders. They then began taking photographs of patients at admission or registration and including these on the above noted verification screen. They found a dramatic reduction in the number of events of actual ordering on the wrong patient or near-misses. And when such events or near-misses did occur, it was usually in charts that did not have a photograph of the patient. While they could not separate out the impact of the verification screen from that of the photograph, they felt that the photographs played a large role in reducing the number of orders placed in the records of wrong patients.
They note that, unlike other CPOE alerts that have a high likelihood of being ignored, the presence of the large centrally placed photograph is effective in capturing the attention of the CPOE user. They do note that photographs have limitations, particularly for newborns and when pictures are poorly exposed. And they note that photographs need to be updated at appropriate times.
There are, of course, other advantages to using patient photographs in healthcare (aside from those that are used for clinical activities such as tracking wound healing, etc.). In our December 2008 What’s New in the Patient Safety World “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting (RSNA 2008) showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
Another study just recently presented (Ridley 2012) also demonstrated that including patient photographs in PACS systems likely leads to fewer misidentification errors. Researchers at Emory University developed a low-cost system for obtaining patient photographs at the time an imaging procedure was being done and integrating them via wireless connection with the images going to their PACS system. They then gave radiologists imaging studies to read that purposefully including some instances of misidentification. Those reading without patient photographs picked up only 12.5% of the misidentified patients. Those reading with the patient photographs detected 64% of the errors.
The American Association for Clinical Chemistry (AACC April 2009) reports some healthcare organizations are attaching patient photos to requisitions for Pap smears or other specimens that are being examined.
In our July 28, 2009 Patient Safety Tip of the Week “” we briefly mentioned using photographs of patients when broadcasting an alert for a missing patient. We recommend that you include in your IT system a digital photograph of patients you identify as being at risk for wandering and elopement. Many communities, often in conjunction with their local chapter of the Alzheimer Association, have programs where families provide photos of their relatives with Alzheimer’s Disease or other dementia to the local police department to facilitate searches when such individuals go missing.
Patient photographs might also be used on patient identification cards issued by a healthcare system. This might help avoid “medical identify theft” or other fraudulent use of identification. Also, you’d be surprised at how issuing identity cards for your health system fosters loyalty to your system. We recall many years ago when our health system stopped issuing patient cards. The patients complained! They liked having them to carry around. It gave them a measure of security and sense of belonging. So don’t underestimate the potential value of such cards.
But are there downsides to using patient photographs? Though there is a paucity of literature on use of patient photographs for patient safety, we can certainly anticipate there might be unintended consequences. Just like many other examples we have seen, it could happen that photographs of two patients get mixed up. For example, one might anticipate two patients being admitted around the same time. Each would get photographed. It is conceivable that someone might print out both photographs and erroneously transpose them into the charts or IT system. That is one reason you should never do anything intended for more than one patient simultaneously.
And what about those patients (eg. trauma patients) whose faces may not be recognizeable on admission? And all those babies in the nursery look the same to me! And some patients, particularly those with long stays, may have considerable changes in appearance over time.
And how do you ensure that your staff actually use the photos to aid in patient identification? In a FMEA performed at one institution () it was found that in those patients with a wristband present and checked, a second form of patient verification (photograph, verification of birthdate, positive response to stated name, etc.) was not checked 30% of the time. So not only is training and reinforcement necessary but some audit function would be appropriate.
We did find a real example of a downside to patient photographs in the literature. In our March 2010 What’s New in the Patient Safety World article “More on Radiation Safety” we reported on an outstanding article that appeared in the journal Radiotherapy & Oncology (Scorsetti et al 2010). Italian researchers performed a FMEA (failure mode and effects analysis) of their entire process of radiation therapy. During their focus on potential misidentification of patients they noted that a photo of each patient had been added to the medical record. However, these photos were often not representative of the patient’s appearance at the time of treatment so staff tended not to rely on the photographs.
Nevertheless, we think that using patient photographs makes a lot of sense in trying to avoid patient misidentification errors. One other common scenario where we think having patient photographs may be very important is the multiple applications/multiple windows scenario. Most health systems still do not have full integration of all their HIT systems. For example, you may be viewing the hospital electronic record for most patient data but may be viewing a radiologic image on the separate PACS system. Particularly if you have been looking through records on multiple patients it is easy to lose synchronization between the two applications so that you may be viewing the EHR on one patient and the PACS images of a different patient. We suspect that having patient photographs, rather than simply name and DOB, on every page in both systems would help avoid this mismatch.
The results of the Children’s Hospital of Colorado study and the Emory University study are very encouraging. We personally think that the addition of photographs to the EHR represent an important patient safety feature. Hopefully, concerns about HIPAA, privacy, and logistical issues can be overcome to apply the concept to multiple areas of patient safety.
AHRQ Health Care. Innovations Exchange. Innovation Profile: Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification.
Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)
RSNA. RSNA Press Release. Patient Photos Spur Radiologist Empathy and Eye for Detail. December 2, 2008
Ridley EL. Integrating digital photos within PACS may cut ID errors. AuntMinnie.com June 20, 2012
AACC. Clinical Laboratory News. April 2009. Patient Safety Focus: Disconnection from Patients and Care Providers. A Latent Error in Pathology and Laboratory Medicine. An Interview with Stephen Raab, MD
Skibinski KA, White BA, Lin LI, et al. Effects of technological interventions on the safety of a medication-use system. Am. J. Health Syst. Pharm., Jan 2007; 64: 90 – 96
Scorsetti M, Signori C, Lattuada P, Urso G, Bignardi M, Navarria P, Castiglioni S, Mancosu P, Trucco P. Applying failure mode effects and criticality analysis in radiotherapy: Lessons learned and perspectives of enhancement.
Radiother Oncol. 2010 Jan 27. [Epub ahead of print]