View as PDF version
Patient Safety Tip
of the Week
November 17, 2020
A Picture Is Worth a Thousand
Words
Ever
since our first electronic health record (EHR) implementation in 2007,
weve been advocates of including patient photographs in the EHR as a means of
avoiding wrong patient events. Its a common sense solution, but evidence confirming
that it actually does reduce such wrong patient errors has been slow to demonstrate.
Our March 24, 2020 Patient Safety Tip
of the Week Mayo Clinic: How to Get
Photos in Your EMR showed how the Mayo Clinic was able to get
patient photographs in to the HER (Aseem 2020). But that study did not measure the
ultimate goal: reduction in patient misidentification errors. In that column we
suggested that, if you were to implement such a project in your organization,
you might use the RAR (Retract-and-Reorder) methodology (see our July 17, 2012
Patient Safety Tip of the Week More on Wrong-Patient CPOE) to
identify instances where a user initially entered an order on the wrong patient. Now a new study does just that.
Salmasian and
colleagues (Salmasian 2020)
compared wrong-patient order entry (WPOE) errors between patients visiting the
ED who had a photograph in their EHR with those who did not. They found that
the risk of WPOE errors was significantly lower when the patients photograph
was displayed in the EHR (odds ratio 0.72). Moreover, this simple
intervention was noninterruptive and had minimal risk
of alert fatigue.
Many other clinical decision support tools to
help avoid wrong patient orders rely on presentation of alerts that can
interrupt clinician workflow and lead to alert fatigue. In the current study,
inclusion of patient photographs was a passive intervention. Though the study
was not a truly randomized controlled study (patients were encouraged to get
their photographs taken and included in the EHR as a potential patient safety
issue), retrospective comparison of the two cohorts was reasonable.
Wrong patient order errors were measured using
the wrong-patient retract-and-reorder (RAR) measure, which is a validated
measure endorsed by the National Quality Forum. Weve discussed the RAR measure
in numerous columns on patient misidentification listed below (see, for
example, our July 17, 2012 Patient Safety Tip of the Week More on Wrong-Patient CPOE).
The authors did acknowledge some of the
barriers encountered in obtaining patient photographs. They note that this can
be difficult in the ED setting because of time pressures and because severely
ill patients may not be amenable to being asked for or consenting to capturing
their photographs. But they note that photographs captured in other settings
(at ambulatory clinics, at inpatient admitting offices, or by scanning the
patients identification card at the time of creating a record) are then
available and displayed in the EHR when patients are in the ED as well. Many
patient portals and mobile apps also allow patients to upload their own
photographs. They also acknowledge, as we have often expressed, there is a need
for organizations to have a policy of when photographs should be updated to
ensure the photographs accurately reflect the patients.
Interestingly, they found that the sickest
patients, who were less likely to end up in the photograph group, also had notably
lower odds of wrong-patient errors. The authors felt that this could be attributable
to the higher level of attention these patients receive from their
practitioners, reducing the chances of a wrong-patient error. Or it might be
the type of orders placed for critically ill patients being different from
orders placed for other patients, such that practitioners are more likely to
catch these errors before placing those orders for the wrong patient.
The authors attribute much of the success to high
levels of engagement by the registration staff and the patients. They note that
this whole process is relatively inexpensive to implement. The costs include
the time used to train the staff on taking photographs, time spent by managers
of the patient registration team to monitor photograph capture adherence and
troubleshoot issues as they arose, and the cost of the equipment used for capturing
photographs, and equipment costs. For the study, they only had to purchase 6
handheld devices and supporting accessories for a total of less than $1600,
plus estimated annual operating costs for maintenance and replacement of
equipment of approximately $1000. They speculate that the expected savings from
improved safety would far outweigh those costs.
Our March
24, 2020 Patient Safety Tip of the Week Mayo Clinic: How to Get
Photos in Your EMR showed how the Mayo Clinic was able to get
patient photographs in to the EHR (Aseem 2020). They did encounter some barriers and it
took several PDSA cycles to accomplish their goal but, ultimately, they also concluded
that the intervention can be implemented inexpensively and without significant
impact on workflow.
The ED is an area particularly prone to wrong-patient
order entry errors because clinicians are often caring for multiple patients
simultaneously, are multitasking, and often have more than one patient record
open at a time. Having more than one record open simultaneously is a
significant risk factor for WPOE errors (see our May 21, 2019 Patient Safety Tip of the Week Mixed Message on Number of
Open EMR Records).
The ability
to reduce wrong patient orders in a nonobtrusive manner is important. Some
interventions that have been successful use alerts that pop up during order
entry requiring the clinician to verify the patients identity. These could
contribute to alert fatigue. Our June 26, 2012 Patient Safety Tip of the
Week Using
Patient Photos to Reduce CPOE Errors described how Childrens Hospital of
Colorado successfully implemented use 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 noted 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 did 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.
Our December 17, 2019 Patient Safety Tip of
the Week Tale of Two Tylers
showed a glaring example of how patient photographs in the EMR might prevent a
wrong patient error. It also described the mechanical steps another hospital
uses to get patient photographs into the EMR. In a study by Blanchfield
et al. (Blanchfield 2019) the
patient photographs were taken when the patient presented to the ED. The ease
with which we can today take a digital photograph today and upload it to the
EHR enables the use of up-to-date patient photos. In the Blanchfield
study, they created a new standard of care and implemented a new workflow for
ED registration staff. Using iPod touch devices, ED registration staff took
photos of consenting patients either at the front desk when patients check-in,
or at the end of the registration process.
We
refer you back to our March 24, 2020 Patient Safety Tip of the Week Mayo Clinic: How to Get
Photos in Your EMR for a discussion of several other benefits
of patient photographs in the EHR. The time has clearly come for healthcare
organizations to include patient photographs in their electronic health
records.
Some of our prior columns on use of
patient photographs in patient safety:
December
2008 Patient Photographs Improve
Radiologists Performance
January 12, 2010 Patient
Photos in Patient Safety
June 26, 2012 Using Patient Photos to Reduce CPOE Errors
April 30, 2013 Photographic
Identification to Prevent Errors
January 19, 2016 Patient
Identification in the Spotlight
March 26, 2019 Patient
Misidentification
November 12, 2019 Patient Photographs Again
Help Radiologists
December 17, 2019 Tale of Two Tylers
March
24, 2020 Mayo Clinic: How to Get
Photos in Your EMR
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
References:
Aseem S, Ratrout BM, Litin SC, et al. A
Process of Acceptance of Patient Photographs in Electronic Medical Records to
Confirm Patient Identification. Mayo Clinic Proceedings: Innovations, Quality
& Outcomes 2020; 4(1): 99-104
https://mcpiqojournal.org/article/S2542-4548(19)30152-3/fulltext
Salmasian H, Blanchfield BB, Joyce K, et al. Association of Display of Patient
Photographs in the Electronic Health Record With Wrong-Patient Order Entry
Errors. JAMA Netw Open 2020; 3(11): e2019652
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772798?resultClick=3
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):
e211-e219
https://pediatrics.aappublications.org/content/130/1/e211?download=true
Blanchfield BB, Salmaisian H, Landman A. Abstract #56. Adding Patient
Photos to the Electronic Health Record to Improve Patient Identification and
Reduce Wrong Patient Order Errors. Ann Emerg Med
2019; 74(4s): S22-23 October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
Print PDF version
|
|
http://www.patientsafetysolutions.com/