The Montefiore Medical Center, www.montefiore.org, and Brigham and Women’s Hospital www.brighamandwomens.org received $300,000 in grant funding from AHRQ to study the impact of health IT on patient safety. The research will directly address “wrong patient” electronic orders, an important clinical patient safety issue impacted by health IT.
Upon completion of the study, it will be the first time IT leaders will have data on the risk of “wrong patient” errors when a varying number of clinical records are opened at once. This information will help determine the best format for Computerized Provider Order Entry (CPOE) systems.
Principal Investigator on the project Jason Adelman, M.D. Patient Safety Officer at Montefiore Medical Center www.montefiore.org/commitment-to-quality-care said, “We propose to do a prospective observational study to examine the relationship between the number of records open when placing an order and the risk of placing an order on the “wrong patient.”
A national survey of Chief Medical Information Officers conducted by Montefiore in March 2014 demonstrated a lack of consensus on the safest number of patient records to be opened at one time.
Of the 91 respondents, 76 had CPOE systems capable of simultaneously displaying multiple patient records. Among 76 respondents, there was marked heterogeneity in the number of records allowed open by IT leadership with several hospitals changing their settings after the initial configuration. Some changed their system to allow more records to open while others decided to limit their system to only one record at a time.
To do the study, a tool was used that was developed at Montefiore called the Retract-and-Reorder tool. The tool is able to detect orders placed on a patient and then placed by the same clinician on a different patient.
The tool detects “wrong patient” orders that are near miss events. The research will also include a two-armed crossover pilot study that will evaluate the wrong patient error rate when the system is configured to allow only one record open at a time as compared to a system configured to allow a maximum of four records to be open at one time.