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Commentary

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

Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7.

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September 29, 2010
Tarpey K, Schaaf E, Lakhani U, et al. Jt Comm J Qual Patient Saf. 2010;36(10):461-7.
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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.

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Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7.

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