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PSNet: Patient Safety Network
Journal Article

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, et al. Journal of the American Medical Informatics Association : JAMIA. 2013;20:477-81.

Wrong-patient errors have long been a risk in hospitals. In one seminal case, a patient underwent an invasive procedure intended for another patient with a similar name. In the era of electronic medical records, errors such as entering notes or ordering medications for the wrong patient may occur as a consequence of multitasking. This AHRQ-funded study evaluated the effectiveness of an alert system, which required entry of an appropriate clinical diagnosis, at preventing wrong-patient medication errors in a computerized provider order entry system. Although the system did correctly identify and prevent incorrect prescriptions, 4000 alerts were required to prevent a single error. Other studies have successfully used forcing functions, or simply placing the patient's photograph on the order screen, to prevent wrong-patient errors.