Journal Article

A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.

Tarpey K, Schaaf E, Lakhani U, et al. Joint Commission journal on quality and patient safety. 2010;36:461-7.

Although sound-alike medications are a well-recognized source of errors, this study addresses a little-studied problem—sound-alike physician names. As the article notes, only 24% of practicing physicians in the United States have a unique last name, raising the potential for errors associated with physician misidentification. When the issue was raised by a physician with a common last name during executive walk rounds, the institution conducted a failure modes effect analysis that identified several critical flaws in the physician identification process. Solutions implemented as a result included forcing functions within the electronic medical record, ensuring that orders and test results could not be misassigned to similarly named physicians.