Intercepting wrong-patient orders in a computerized provider order entry system

Abstract

Study objective: We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 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 inpatients were used as a parallel control. After 2 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 seconds) 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 computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.

Figure 1

Screenshot of the patient verification dialog that appeared prior to order entry. The “Continue” button is disabled for 2.5 seconds when the dialog is displayed.

Figure 2

The rate of wrong-patient orders in each month, per 1000 orders. Dashed lines show the average rate of wrong-patient orders in each segment detected in the data using change-point analysis. Shaded areas show the study periods: pre-intervention (P1), short-term follow-up after intervention (P2), and long-term follow-up after intervention (P3).