title: Intercepting wrong-patient orders in a computerized provider order entry system.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Emergency Medicine, Columbia University Medical Center and NewYork-Presbyterian Hospital, New York, NY; Division of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, NY. Electronic address: greerob@nyp.org.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Green
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY; Medical Informatics Services, NewYork-Presbyterian Hospital, New York, NY.
authors.forename: George
authors.initials: G
authors.lastname: Hripcsak
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY.
authors.forename: Hojjat
authors.initials: H
authors.lastname: Salmasian
authors.affiliation: Division of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, NY.
authors.forename: Eliot J
authors.initials: EJ
authors.lastname: Lazar
authors.affiliation: Department of Pediatrics, Weill Cornell Medical College, New York, NY.
authors.forename: Susan B
authors.initials: SB
authors.lastname: Bostwick
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY; School of Nursing, Columbia University, New York, NY.
authors.forename: Suzanne R
authors.initials: SR
authors.lastname: Bakken
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY; Medical Informatics Services, NewYork-Presbyterian Hospital, New York, NY.
authors.forename: David K
authors.initials: DK
authors.lastname: Vawdrey
mesh_terms: D000328:Adult; D002648:Child; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D050316:Medical Order Entry Systems / Q000458:organization & administration / Q000706:statistics & numerical data; D061214:Patient Safety