Intercepting Wrong-Patient Orders in a Computerized Provider Order Entry System

Abstract

Study Objective We evaluated the short- and long-term impact of a computerized provider entry (CPOE)-based patient verification intervention to reduce wrong-patient orders in five emergency departments. Methods A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5–second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. Results Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when using inpatients as a parallel control. After two years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD = 4.0), and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. Conclusion A CPOE-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at the time of entry is an important step in reducing these errors.

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