Understanding and preventing wrong-patient electronic orders: a randomized controlled trial

Adelman, Jason S.; Kalkut, Gary; Schechter, Clyde B.; Weiss, Jeffrey M.; Berger, Matthew; Reissman, Stan; Cohen, Hillel W.; Lorenzen, Stephen J; Burack, Daniel A; Southern, William N.

doi:10.1136/amiajnl-2012-001055

Cited by 107 publications

(172 citation statements)

References 21 publications

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“…Assuming a baseline error rate of 60 RAR events per 100 000 orders, 13 and assuming an estimated effect size that was based on previous wrong-patient error research, 6 our study duration of 1 year of control data collection and 1 year of intervention data collection provided .90% power to detect a 40% reduction in the odds of an RAR event. The effect size (ie, 40% reduction in RAR events) that we used for this calculation is taken from the results of a randomized controlled trial that evaluated the efficacy of an improved patient identification system for preventing wrong-patient electronic orders.…”

Section: Discussionmentioning

confidence: 99%

“…Previous research suggested that 76.2% of RAR events represent wrong-patient errors. 6 RAR events are near-miss errors, self-caught by the clinician before they reach the patient. The Eunice Kennedy Shriver National Institute of Child Health and Human Development defines near-miss errors as "those errors that do not result in patient harm due to chance or timely interventions."…”

Section: Figurementioning

confidence: 99%

“…6 The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the…”

Section: Outcome Measurementioning

confidence: 99%

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Use of Temporary Names for Newborns and Associated Risks

et al. 2015

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Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors.

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Section: Discussionmentioning

confidence: 99%

Section: Figurementioning

confidence: 99%

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Use of Temporary Names for Newborns and Associated Risks

et al. 2015

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“…Multiple safety publications have addressed computerized physician order entry (CPOE) associated gains in safety (eliminating prescriber handwriting errors), as well as its unintended consequences due to screen arrangement, data entry errors (weight in pounds instead of kilograms), and wrong-patient orders [45,46]. The ED medication safety team identified multiple local CPOE problems, such as the appearance of a medication on the ordering screen and trade/generic name confusion.…”

Section: Multidisciplinary Teamworkmentioning

confidence: 99%

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

Smith

Farmer

2015

J. Med. Toxicol.

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Medical and medication errors remain definite threats to patients in US health care. Medical toxicologists frequently encounter patients either harmed by or at risk for harm from adverse drug events, including medication errors and inadvertent exposures. An historical perspective, as viewed through the lens of specific disciplines, can be useful to trace systemic responses to safety threats. Early efforts to address anesthesia perioperative risks and recent actions in medicine, surgery, and obstetrics to introduce checklists, communication tools, and systems approaches are reviewed. Patient safety concepts can be utilized and disseminated by toxicologists to improve medication safety and drive innovative approaches to confront patient harm. Various approaches include simulation of high-risk scenarios which might predispose to medication error, assembling multidisciplinary groups of health care providers to review events and implement mitigation strategies, and proactive patient safety rounds in clinical areas to allow frontline staff to voice concerns and introduce solutions for administration, evaluation, and implementation. We review selected lessons from the past and current innovations to achieve safe medication practice.

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“…Wrong patient errors which have the potential to lead to diagnostic errors have received attention. In one study, a health IT safety measure, known as the Retract-and-Reorder measure, was introduced as a tool hospitals can utilize to examine "near misses" of wrong patient error so that subsequent preventive action could be taken [25].…”

Section: Detecting Safety Riskmentioning

confidence: 99%

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

et al. 2017

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Background: The Improving Diagnosis in Health Care report from the National Academies of Sciences, Engineering and Medicine (NASEM) provided an opportunity for many groups to reflect on the role they could play in taking actions to improve diagnostic safety. As part of its own process, AHRQ held a research summit in the fall of 2016, inviting members from a diverse collection of organizations, both inside and outside of Government, to share their suggestions regarding what is known about diagnosis and the challenges that need to be addressed. Content: The goals of the summit were to learn from the insights of participants; examine issues associated with definitions of diagnostic error and gaps in the evidence base; explore clinician and patient perspectives; gain a better understanding of data and measurement, health information technology, and organizational factors that impact the diagnostic process; and identify potential future directions for research. Summary and outlook: Plenary sessions focused on the state of the new diagnostic safety discipline followed by breakout sessions on the use of data and measurement, health information technology, and the role of organizational factors. The proceedings review captures many of

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Understanding and preventing wrong-patient electronic orders: a randomized controlled trial

Abstract: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

Cited by 107 publications

References 21 publications

Use of Temporary Names for Newborns and Associated Risks

Use of Temporary Names for Newborns and Associated Risks

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

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