Requiring health care providers to re-enter patient identification numbers in a computerized provider order entry system significantly reduced the number of orders submitted for the wrong patient, according to a study published in the Journal of the American Medical Informatics Association, FierceHealthIT reports (Hall, FierceHealthIT, 7/2).
Study Details
For the study, researchers evaluated wrong-patient orders at four hospitals by using a tool that identified instances in which a clinician submitted an order for a specific patient, then retracted the order and submitted the same order for a different patient (Adelman et al., JAMIA, 6/29).
Researchers then set up a three-part study that examined the frequency of wrong-patient orders among:
- Health care providers required to re-enter patient identification numbers;
- Health care providers required to submit a single-click confirmation of patient identity; and
- A control group with no intervention.
After conducting phone interviews, researchers identified 170 of 223 retract-and-reorder events as wrong-patient orders.
Study Findings
Compared with the control group, researchers found that:
- Requiring clinicians to re-enter patient identification numbers reduced wrong-patient orders by 41%; and
- Requiring clinicians to submit a single-click confirmation of patient identity reduced wrong-patient orders by 16%.
However, researchers noted that requiring clinicians to re-enter patient identification numbers added 6.6 seconds to the time spent placing each order, which could lead to other patient care and physician workflow issues.
Recommendations
The researchers wrote, "All hospitals that implement CPOE systems should consider measuring retract-and-reorder events to estimate the frequency of wrong-patient orders and optimize their software to minimize these errors."
They also recommended further study of wrong-patient orders among different hospital departments (FierceHealthIT, 7/2).