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Patient Safety Tip
of the Week
August
3, 2021
Obstetric
Patients More At-Risk for Wrong Patient Orders
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 medicalsurgical 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
medicalsurgical 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.
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
weve 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.
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 Doesnt 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?
References:
Kern-Goldberger AR, Kneifati-Hayek
J, Fernandes Y, et al. Wrong-Patient Orders in Obstetrics. Obstetrics &
Gynecology 2021; Published online July 8, 2021
https://journals.lww.com/greenjournal/Fulltext/9900/Wrong_Patient_Orders_in_Obstetrics.235.aspx
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