Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.
Approach to Improving Safety
Setting of Care
Patient misidentification errors—such as laboratory results or notes being entered into the wrong patient chart—have been shown to occur in the emergency department and inpatient settings. Misidentification errors have the potential for serious patient harm when combined with computerized provider order entry, as patients could receive unintended medications. In this study, investigators at an academic medical center first developed a measurement tool within their electronic medical record to identify wrong-patient orders (and found that they were surprisingly common), then conducted a randomized trial investigating the efficacy of two different strategies to prevent wrong-patient orders. A forcing function that mandated re-entry of patient identifiers before allowing order entry resulted in significant reduction in wrong-patient orders. In another study, simply placing the patient's photograph on the order entry screen also appeared to reduce wrong-patient orders.