title: "I meant that med for Baylee not Bailey!": a mixed method study to identify incidence and risk factors for CPOE patient misidentification.
abstract: Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.
authors.affiliation: Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Hannah I
authors.initials: HI
authors.lastname: Levin
authors.forename: James E
authors.initials: JE
authors.lastname: Levin
authors.forename: Steven G
authors.initials: SG
authors.lastname: Docimo
mesh_terms: D000367:Age Factors; D016022:Case-Control Studies; D003625:Data Collection; D034742:Electronic Mail; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D009275:Names; D010355:Patient Identification Systems; D012307:Risk Factors