Patient Safety Tip of the Week


May 20, 2008

CPOE Unintended Consequences – Are Wrong Patient Errors More Common?






In our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” we noted several unintended consequences of Computerized Physician Order Entry (CPOE). We’ll be discussing more unintended consequences of CPOE in the future.



But there is one issue we’d like to bring up now that seems to have escaped attention in the published literature on unintended consequences of CPOE – are “wrong patient” errors more likely to occur after CPOE implementation? We don’t know of any study that has statistics about this but there are many practical considerations that may increase the risk of orders being inadvertently entered on the wrong patient with CPOE.



First and foremost is the fact that with CPOE orders are often being entered remotely, that is not at the patient’s bedside. We previously cited examples of unintended consequences of remote order entry. An issue of ISMP’s newsletter a year ago had an example of a nonventilated patient inadvertently being given a paralytic agent, in part because the ordering physician was entering orders from a remote site and accidentally ordered this for the wrong patient.



One might argue that in the old paper-based system we also often enter orders remotely. We often take a chart from the patient chart rack in the nursing station and enter orders there. Certainly one could pick up the wrong chart and begin writing orders there. But there are several factors that probably make it more likely during CPOE and you need to address them during your CPOE implementation to minimize the risk of this unintended consequence. Below are 5 common scenarios that can lead to entering orders on the wrong patient via CPOE:



Patient name and other ID items not appearing on every screen

We’ve seen systems where navigation clicks or scrolling remove these critical identifiers from the screen. You need to ensure that the name and other identifiers remain anchored at the top of every screen of your CPOE system. (And remember to make your identifiers consistent with your Joint Commission-capatible patient identification policy).



The cursor/stylus error
The same error one sees with selecting a drug from a drop-down list obviously can also occur when selecting a patient from a drop-down list. We call this a cursor error when it occurs while using a larger data entry device, and a stylus error when using a PDA-type entry device. There errors are probably more common with the latter devices. There are no quick fixes for these, though thoughtful screen layouts can minimize the risk of these errors.



The “truncated scroll” syndrome

When searching for a specific patient, the results list may be longer than the current screen. The physician may simply pick the last name on the screen if it looks like the one he/she is looking for, failing to realize that there may be more patients with that name (he/she would have to continue scrolling the list to see them). You need to attempt to prevent your patient searches from “splitting” patients with like names in any screen window (or otherwise alert the user to scroll because there may be more similar names).


You would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al (2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.



The dual system issue

Many, if not most, hospitals have developed intranet systems that display useful clinical information on patients before they have implemented CPOE. Particularly with some CPOE systems that have limited integration with other systems, it is not uncommon for a physician to look at information on the older intranet 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.



The failure to log off issue


This occurs when a physician leaves the order entry screen temporarily without logging off and a second physician comes by and leaves orders on a patient (without logging on separately). The first physician then returns to the screen and assumes that he/she is still entering orders on the original patient.




Though “wrong patient” errors have not shown up on the lists of common unintended consequences of CPOE, that may simply reflect that they are less common than many of the other unintended consequences. However, they have the potential to cause more serious patient harm.







Institute for Safe Medication Practices. Remote CPOE error—a situation that’s more than remotely possible. ISMP Newsletter. May 31, 2007.



Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003.



Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, Plsek P, Goldmann DA, Horbar J. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006;117;e43-e47




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