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Patient Safety Tip of the Week

August 3, 2021

Obstetric Patients More At-Risk for Wrong Patient Orders



We’ve done many columns on patient misidentification and wrong patient orders. There are, of course, some patient-related factors that put patients at greater risk of wrong patient events – such as having very common last names. But we’ve always presumed that patients would be equally at risk for wrong patient orders regardless of site in the healthcare system. A new study shows that may not be the case.


Kern-Goldberger and colleagues (Kern-Goldberger 2021) used the “retract-and-reorder” method (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify near-miss wrong patient orders and compared rates of such orders among patients on obstetric units to those for reproductive-aged women admitted to medical–surgical units. They found the rate of such orders on obstetric patients was nearly double that seen on general med-surg units. The rate of retract-and-reorder events per 100,000 order sessions in obstetric units was 79.5, compared to 42.3 in the general medical–surgical population (OR 1.98). The obstetric retract-and-reorder event rate was significantly higher for attending physicians and house staff compared with advanced practice clinicians. There were no significant differences in error rates between day and night shifts.


By definition, instances found by the retract-and-reorder method did not result in actual wrong patient errors (because the error was rapidly identified and corrected). Nevertheless, they do provide a reasonable estimate of the comparable frequency of actual wrong patient order errors.


Medications most frequently subject to error in the obstetric population in this study were non-oxytocin uterotonics, nifedipine, antibiotics, opioid and non-opioid analgesics, and tocolytics. While the confidence intervals were too wide to make firm conclusions about the risks for these medication categories, they are similar to those found in other studies showing higher error rates for antibiotics, opioid analgesics, tocolytics, and magnesium sulfate in the obstetric population.


The authors discuss potential factors contributing to the higher frequency of wrong patient orders on obstetrics units. One is that the patients are similar in terms of age, sex, and reason for admission. Another is the rapidly changing clinical status of patients in labor and delivery settings. And clinicians are often entering orders for multiple patients at the same order entry sitting. Also, their order entry may be interrupted by obstetric emergencies or imminent deliveries.


In attempt to explain the disparity in wrong patient orders between physicians (attendings and residents) and advanced practice clinicians, the authors note that the physicians are more likely to be entering orders on busy labor and delivery units, whereas the advanced practice clinicians are more likely entering orders in triage, antepartum, and postpartum settings (which might be less hectic).


The study is not clear on one item – the impact of babies having the same last name as the moms. Our multiple columns on misidentification of newborns points out that newborns usually have the same last name as the moms and often share a last name with their twin or other multiple birth sibling. But given the types of medications most frequently involved, it is unlikely that those were being ordered for newborns. So, we doubt much of an impact due to babies having the same last names as moms here.


The authors suggest helping clinicians place orders without disturbance, such as adopting a mandated “no disruption” culture while orders are being placed or other safety tools to protect physicians and advanced practice clinicians from distraction and interruption. They also suggest better balancing clinical responsibilities for all obstetric clinicians, especially house staff, to ensure adequate time and attention to enter orders safely.


They discuss other factors that frequently contribute to patiens safety issues, such as workload and clinician/patient ratio, crossover coverage and covering multiple services simultaneously, and handoffs.


They also discuss many of the interventions we’ve discussed to avoid wrong patient errors, such as requiring electronic confirmation of patient identity before signing an order, EMR-generated warnings about patients with similar names, use of patient photographs, and CDS alerts regarding high alert or common medications.


Your EMR/CPOE system should always include patient identification information on every page (fixed, so it is not lost when scrolling) and we advocate use of patient photographs in addition to the names and other identifiers. In addition, a good EMR/CPOE system will prevent drop-down lists of patients from stopping at the first search name or at least use some sort of mechanism to alert the clinician that there are more patients with the same search name. And we again caution against allowing multiple patient records to be open at the same time (that also means you need to synchronize records if you have more than one IT program running at the same time, such as CPOE and a separate radiology system).


We also strongly advocate use of the retract-and-reorder” tool as a means of identifying your vulnerabilities to wrong patient orders.


Our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” has many recommendations on avoiding wrong patient orders, as do the multiple other columns listed below.



Some of our prior columns related to patient identification issues:

May 20, 2008              “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”

November 17, 2009    “Switched Babies”

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”

August 1, 2017           “Progress on Wrong Patient Orders”

June 19, 2018              “More EHR-Related Problems”

November 2018          “More on Hearing Loss”

March 26, 2019           “Patient Misidentification”

May 21, 2019              “Mixed Message on Number of Open EMR Records”

September 10, 2019    “Joint Commission Naming Standard Leaves a Gap”

December 17, 2019     “Tale of Two Tylers”

March 24, 2020           “Mayo Clinic: How to Get Photos in Your EMR”

June 16, 2020              “Tracking Technologies”

November 17, 2020    “A Picture Is Worth a Thousand Words”



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”

August 1, 2017           “Progress on Wrong Patient Orders”

March 26, 2019           “Patient Misidentification”

September 10, 2019    “Joint Commission Naming Standard Leaves a Gap”

June 16, 2020              “Tracking Technologies”




Some of our previous columns on maternal and ob/gyn issues:

February 5, 2008         “Reducing Errors in Obstetrical Care”

February 2010             “Joint Commission Sentinel Event Alert on Maternal Deaths”

April 2010                   “RCA: Epidural Solution Infused Intravenously”

July 20, 2010              “More on the Weekend Effect/After-Hours Effect”

August 2010               “Surgical Case Listing Accuracy”

September 7, 2010      “Patient Safety in Ob/Gyn Settings”

January 2011               “Surgical Fires Not Just in High Risk Cases”

February 8, 2011         “Inducing Too Early”

April 2011                   “Ob/Gyn Patient Safety Programs”

April 24, 2012             “Fire Hazard of Skin Preps Oxygen”

July 2012                    “WHO Safe Childbirth Checklist”

December 4, 2012       “Unintentional Perioperative Hypothermia: A New Twist”

September 2013          “Full-Time Laborists Reduce C-Section Rates”

October 2013              “Challenging the 39-Week Campaign”

November 2013          “The Weekend Effect: Not One Simple Answer”

January 2014               “It MEOWS But Doesn’t Purr”

May 13, 2014              “Perioperative Sleep Apnea: Human and Financial Impact”

August 19, 2014         “Some More Lessons Learned on Retained Surgical Items”

November 3, 2015      “Medication Errors in the OR - Part 2”

February 7, 2017         “Maternal Safety Bundles”

January 23, 2018         “Unintentional Hypothermia Back in Focus”

January 8, 2019           “Maternal Mortality in the Spotlight”

December 8, 2020       “Maternal Mortality: Looking in All the Wrong Places?”






Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-Patient Orders in Obstetrics. Obstetrics & Gynecology 2021; Published online July 8, 2021






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