Providers do not verify patient identity during computer order entry.
BACKGROUND
Improving patient identification (ID), by using two identifiers, is a Joint Commission safety goal. Appropriate identifiers include name, date of birth (DOB), or medical record number (MRN).


OBJECTIVE
The objectives were to determine the frequency of verifying patient ID during computerized provider order entry (CPOE).


METHODS
This was a prospective study using simulated scenarios with an eye-tracking device. Medical providers were asked to review 10 charts (scenarios), select the patient from a computer alphabetical list, and order tests. Two scenarios had embedded ID errors compared to the computer (incorrect DOB or misspelled last name), and a third had a potential error (second patient on alphabetical list with same last name). Providers were not aware the focus was patient ID. Verifying patient ID was defined as looking at name and either DOB or MRN on the computer.


RESULTS
Twenty-five of 25 providers (100%; 95% confidence interval [CI] = 86% to 100%) selected the correct patient when there was a second patient with the same last name. Two of 25 (8%; 95% CI = 1% to 26%) noted the DOB error; the remaining 23 ordered tests on an incorrect patient. One of 25 (4%, 95% CI = 0% to 20%) noted the last name error; 12 ordered tests on an incorrect patient. No participant (0%, 0/107; 95% CI = 0% to 3%) verified patient ID by looking at MRN prior to selecting a patient from the alphabetical list. Twenty-three percent (45/200; 95% CI = 17% to 29%) verified patient ID prior to ordering tests.


CONCLUSIONS
Medical providers often miss ID errors and infrequently verify patient ID with two identifiers during CPOE.
Henneman
Philip L
PL
Department of Emergency Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA. philip.henneman@bhs.org
Fisher
Donald L
DL
Henneman
Elizabeth A
EA
Pham
Tuan A
TA
Mei
Yi Y
YY
Talati
Rakesh
R
Nathanson
Brian H
BH
Roche
Joan
J
D016001:Confidence Intervals; D003657:Decision Making; D005133:Eye Movements; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D050316:Medical Order Entry Systems; D010355:Patient Identification Systems; D011446:Prospective Studies; D011785:Quality Assurance, Health Care