Electronic Medical Records, Medical Errors
Conditions
Keywords
Allscripts, Epic, Electronic Health Record (EHR), Electronic orders
Brief summary
This is a multi-site, 4-arm randomized controlled trial to test the effectiveness of patient photographs displayed in electronic health record (EHR) systems to prevent wrong-patient order errors. The study will be conducted at several academic medical centers that utilize two different EHR systems. Because EHR systems have different functionality for displaying patient photographs, two different study designs will be employed. In Allscripts EHR, a 2-arm randomized trial will be conducted in which providers are randomized to view order verification alerts with versus without patient photographs when placing electronic orders. In Epic EHR, a 2x2 factorial trial will be conducted in which providers are randomized to one of four conditions: 1) no photograph; 2) photograph displayed in the banner only; 3) photograph displayed in a verification alert only; or 4) photograph displayed in the banner and verification alert. The main hypothesis of this study is that displaying patient photographs in the EHR will significantly reduce the frequency of wrong-patient order errors, providing health systems with the evidence needed to adopt this safety practice.
Detailed description
Although Computerized provider order entry (CPOE) systems are associated with a reduction in medical errors, when orders are placed electronically certain types of errors, including placing orders on the wrong patient, may occur more frequently. The danger of wrong-patient electronic orders was highlighted by one hospital's report of over 5,000 wrong patient orders in 1 year. With the growing use of electronic health records (EHRs), an effective method to minimize wrong-patient orders is needed. One study showed that patient photographs displayed in EHR systems decreased wrong-patient orders from 12 to 3 per year after patient photographs were implemented. While encouraging, this study was limited due to its small sample size, compared outcomes of the intervention participants to outcomes of a comparison group similar in demographics but may have differed in ways that were not measured in the study (quasi-experimental design), and reliance on voluntary reporting of errors by providers, which is known to be unreliable and greatly underestimate the actual error rate. This research proposes to use an automated and reliable measure of wrong-patient errors instead of voluntary reporting will demonstrate that patient photographs can significantly prevent wrong-patient orders.
Interventions
BEHAVIORALPhoto in Verification Alert
Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.
BEHAVIORALPhoto in Banner
Patient photograph will be displayed in the banner at the top of the screen in the electronic health record.
BEHAVIORALPhoto in Banner and Verification Alert
Patient photograph will be displayed in the banner at the top of the screen in the electronic health record AND patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.
Sponsors
Agency for Healthcare Research and Quality (AHRQ)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Montefiore Medical Center
Brigham and Women's Hospital
Columbia University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* All patients for whom an order was placed in the study period. * All providers with the authority to place electronic orders and who placed electronic orders during the study period.
Exclusion criteria
* None
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure. | 2 years | Using the Wrong-Patient (WP) Retract-and-Reorder measure, the outcome was WP order sessions, defined as series of orders placed by 1 clinician for 1 patient that included ≥1 WP order. The Wrong-Patient Retract-and-Reorder (RAR) measure is an automated, validated, and reliable measure endorsed by the National Quality Forum (NQF #2723). The RAR measure identifies orders placed for a patient that are retracted within 10 minutes, and then placed by the same provider for a different patient within the next 10 minutes. These are near-miss errors, self-caught by the provider before they reach the patient and cause harm. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Photo in Verification Alert Patient photo displayed in a patient ID verification alert when placing electronic orders in the electronic health record.
Photo in Verification Alert: Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record. | 2,171 |
| Photo in Banner Patient photo displayed in the banner (at the top of the screen).
Photo in Banner: Patient photograph will be displayed in the banner at the top of the screen in the electronic health record. | 2,202 |
| Photo in Banner and Verification Alert Patient photograph displayed in the banner (at the top of the screen) AND patient photo displayed in a verification alert when placing electronic orders.
Photo in Banner and Verification Alert: Patient photograph will be displayed in the banner at the top of the screen in the electronic health record AND patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record. | 2,196 |
| No Photo No patient photographs displayed in the electronic health record. | 2,199 |
| Total | 8,768 |
Baseline characteristics
| Characteristic | Photo in Banner | Photo in Banner and Verification Alert | No Photo | Total | Photo in Verification Alert |
|---|---|---|---|---|---|
| Age, Customized >18 years | 2202 Participants | 2196 Participants | 2199 Participants | 8768 Participants | 2171 Participants |
| Race and Ethnicity Not Collected | — | — | — | 0 Participants | — |
| Region of Enrollment United States | 2202 Participants | 2196 Participants | 2199 Participants | 8768 Participants | 2171 Participants |
| Sex: Female, Male Female | — | — | — | 0 Participants | — |
| Sex: Female, Male Male | — | — | — | 0 Participants | — |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 2,171 | 0 / 2,202 | 0 / 2,196 | 0 / 2,199 |
| other Total, other adverse events | 0 / 2,171 | 0 / 2,202 | 0 / 2,196 | 0 / 2,199 |
| serious Total, serious adverse events | 0 / 2,171 | 0 / 2,202 | 0 / 2,196 | 0 / 2,199 |
Outcome results
Primary
Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure.
Using the Wrong-Patient (WP) Retract-and-Reorder measure, the outcome was WP order sessions, defined as series of orders placed by 1 clinician for 1 patient that included ≥1 WP order. The Wrong-Patient Retract-and-Reorder (RAR) measure is an automated, validated, and reliable measure endorsed by the National Quality Forum (NQF #2723). The RAR measure identifies orders placed for a patient that are retracted within 10 minutes, and then placed by the same provider for a different patient within the next 10 minutes. These are near-miss errors, self-caught by the provider before they reach the patient and cause harm.
Time frame: 2 years
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Photo in Verification Alert | Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure. | 5587 WP Order Sessions |
| Photo in Banner | Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure. | 5836 WP Order Sessions |
| Photo in Banner and Verification Alert | Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure. | 5598 WP Order Sessions |
| No Photo | Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure. | 6279 WP Order Sessions |