Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU

Adelman, Jason S.; Aschner, Judy L.; Schechter, Clyde B.; Angert, Robert; Weiss, Jeffrey M.; Rai, Amisha; Berger, Matthew; Reissman, Stan; Yongue, Camille; Chacko, Bejoy; Dadlez, Nina M.; Applebaum, Jo R.; Racine, Andrew D.; Southern, William N.

doi:10.1542/peds.2016-2863

Cited by 30 publications

(44 citation statements)

References 6 publications

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“…16,18 However, several publications related to reports in pediatrics have mostly approached medication errors and their potential consequences. [6][7][8][9][10][11][12]14,[27][28][29][30] Still, in Latin American countries, reporting studies are very scarce compared to developed countries. So much that, to our knowledge, this is the first Argentine study that focused exclusively on reports of medication errors in hospitalized children.…”

Section: Discussionmentioning

confidence: 99%

“…Voluntary reporting is only one of the multiple pieces that are required at hospitals to reduce and detect errors and AEs in order to improve patient safety. 21,[23][24][25][30][31][32] As observed in this study, medication errors are most commonly reported in a voluntary manner. Most likely, these errors are more easily detected in hospitalized children, by both health care providers and patients' parents, who are usually the first ones to notice them.…”

Section: Discussionmentioning

confidence: 99%

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Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

et al. 2019

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Objective. To assess reports of medication errors in hospitalized children to establish their frequency, causes, and adverse events(AEs). Methods. Prospective study of medication errors reported at the Neonatal Intensive Care Unit (NICU), Pediatric Clinic (PC), and Pediatric intensive Care Unit (PICU). Ambulatory Pediatrics reports and incomplete data were excluded. Related variables were evaluated. Results. Out of 989 errors reported in Department of Pediatrics, 401 (41 %) corresponded to medication errors. Of these, 353 (88 %) reached patients and 48 (12 %) were quasi-errors; 42 % occurred in the morning; 24 %, in the afternoon; 17 %, in the morning and afternoon, and 17 %, in the night; differences were not significant (p = 0.18). Dosing errors were the most common ones, 118 (33.4 %). In total, 160 reports (45 %) corresponded to prescription errors; 149 (42 %), to administration errors; and 44 (2.5 %), to dispensing errors. Dosing errors were more common in prescriptions (p < 0.05). The highest number of errors was reported at the NICU, 179 (50 %); compared to 91 (25.5 %) at the PC and 83 (24.5 %) at the PICU. A total of 91 AEs were reported (22.5 %); most were mild, 53 (58 %), or moderate, 31 (34 %). The NICU reported 53 AEs (58 %); the PICU, 25 (27 %); and the DCP, 18 (19.7 %). No deaths occurred. Conclusion. The rate of medication errors reported in hospitalized children was 41 %. Dosing errors were the most common ones. A total of 91 AEs were reported; most were mild (58 %); the highest number was reported at the NICU (58 %).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

et al. 2019

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“…RAR has been successfully used to measure the rate of intercepted wrong-patient errors in various settings including emergency departments, 13,14 a children's hospital, 12 and the NICU setting. 4,5…”

Section: Outcomementioning

confidence: 99%

“…However, previous research has shown the viability of using RAR as a proxy for wrong-patient errors in pediatric and neonatal settings. 4,5 For the analysis, we did not have data on clinician-type breakdowns of wrong-patent errors. We only used the standard 10-minute interval from the RAR events; errors that were identified by other clinicians or those that were caught later in the medication workflow were not included in the analysis.…”

Section: Limitationsmentioning

confidence: 99%

“…sequentially, identical surnames for multiple patients, and multiple births (e.g., twins or triplets) with nearly identical names and MRNs. [3][4][5]9 Strategies to prevent patient misidentification involve double checking of identifiers by clinicians such as MRN and date of birth. However, for newborns' with the same date of birth, sequentially assigned MRNs may be identical except for a single digit.…”

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confidence: 99%

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Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

et al. 2020

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Objectives Newborns are often assigned temporary names at birth. Temporary newborn names—often a combination of the mother's last name and the newborn's gender—are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. We developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy. Methods This study was conducted over a 14-month period in the newborn nursery and neonatal intensive care units of three hospitals that were part of the same health care system. We used a quasi-experimental study design using interrupted time series analysis to compare the differences in wrong-patient orders (an indicator of patient misidentification) before and after the implementation of the alternative distinct naming strategy. Results Overall, there were 25 wrong-patient errors per 10,000 orders during entire study period (36.8 per 10,000 before and 19.6 per 10,000 after). However, there was no statistically significant change in the rate of wrong-patient ordering errors after the transition from the distinct to the alternative distinct naming strategy (β = 0.832, 95% confidence interval [CI] = −0.83 to 2.49, p = 0.326). We also found that, overall, 1.7% of the clinicians contributed to 62% of the wrong-patient errors. Conclusion Although we did not find statistically significant differences in wrong-patient errors, the alternative distinct naming approach provides pragmatic advantages over its predecessors. In addition, the localization of wrong-patient errors within a small set of clinicians highlights the potential for developing strategies for delivering training to clinicians.

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Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors

Adelman

Applebaum

Schechter

et al. 2019

JAMA

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IMPORTANCE Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. OBJECTIVE To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. INTERVENTIONS Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). MAIN OUTCOMES AND MEASURES The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). RESULTS Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20];

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Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU

Abstract: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.

Cited by 30 publications

References 6 publications

Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics

Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors

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